THE Integrative Therapist
ARTICLE S • INTERVIEW S • COMMENTARIES
Volume 6, Issue 4 • Dec 2020 ISSN # 2520-2464 President's Column Shigeru Iwakabe Mission Statement The Society for the Exploration of Psychotherapy A while ago when covid-19 was somewhat Integration (SEPI) is an international, interdis- controlled and the Japanese government started a ciplinary organization whose aim is to promote campaign called “Go-To-Eat” to re-activate its the exploration and development of approaches to psychotherapy that integrate across theoretical economy while establishing safety, I had a chance orientations, clinical practices, and diverse to go out to a restaurant. The experience was methods of inquiry. engraved in my memory. As soon as I entered the door, my five senses were hit by a myriad of pleasant and exciting stimuli: many layers of aromas of freshly-cooked dishes being carried to tables by waiters, the orchestra of sounds created by utensils, music, people talking, and waiters rhythmically and swiftly walking through tables as if they are performing on a small stage. It felt so nice to see groups of strangers and their smiling faces. I also noticed my curiosity was stimulated by wondering about who they were and what occasions they were there for. All these things Alexandre Vaz came together to make the space alive. A couple of hours at the restaurant felt like a full Editor celebration of everyday life: I felt so much energy and aliveness around me and at the same time I felt relaxed and content. No wonder we long for congregating and gathering, and 3Cs are so hard to resist. We have yearning for closeness, contact, and crowding. There are over 38,000 restaurants in Tokyo where I live. Each must hold different liveliness and create a unique space.
SEPI’s annual meetings that we all love are also full of fascinations: learning cutting-edge work in progress that sparks our inquiring mind, presenting your latest work and getting Sasha Rudenstine feedback from colleagues who share the integrative spirit yet hold divergent views, intriguing Associate Editor conversations in sessions and also at coffee breaks, learning creative ways in which its n members integrate research and practice, reuniting and catching up with your friends and In This Issue colleagues, meeting your future colleagues, engaging and relaxing conversations at poster President's Column sessions with a drink, Saturday night gala to celebrate our successful meeting and looking by Shigeru Iwakabe ...... 1 ahead, visiting beautiful cities around the world, and the list goes on endlessly. SEPI creates SEPI Regional Networks Update its own unique space like no other. We all play an important part in it bringing unique by Tom Holman and Doménica Klinar ...... 3 contributions from all over the world. SEPI Regional Network Award Winner 2019 by Ueli Kramer ...... 4 The next meeting is set forth. The theme is “Working with emotion in psychotherapy: Clients, Upcoming SEPI Webinar ...... 6 diagnoses, Methods”. This theme will probably interest many SEPI members and also almost Improving therapy effectiveness through all psychotherapists and researchers. I have no doubt that we will have very active and reliable, personalized case formulation stimulating presentations and discussions on the topic. by David Kealy & George Silberschatz...... 7
Table of Contents continues... The Integrative Therapist Volume 6, Issue 4 • Dec 2020
The race to transforming mental healthcare through cutting edge technologies Under the leadership of the program chair and president-Elect Alberta Pos and Local by Ioana Podina ...... 10 Host Ueli Kramer, we have been working on planning the next meeting, which will be a Can we bring psychotherapy research closer to hybrid meeting permitting both in-person and online access. If the covid-19 situation the complexity of human nature? improves, some of us will be in beautiful Lausanne, Switzerland, and others will join by Sasha Rudenstine & Talia Schulder ...... 13 online from wherever they are.
The Experiential Revolution This hybrid meeting is new to us and will not be the same SEPI meeting as we know it. by Giancarlo Dimaggio ...... 16 However, we still hope that it will bring us together and we can hold a SEPI space both Final words from current Editor and in person and online and have the two spaces connected. introducing our new SEPI Newsletter Editor
by Alexandre Vaz & Alan Kian ...... 20 I hope that SEPI can make the best out of the current challenge to cultivate and develop some of the important trademarks of SEPI: our dialogue, collaboration and rewarding collegial relationships among its members. Our next meeting will be a great opportunity to start exploring how we can cultivate and develop the SEPI spirit online n and throughout the year.
This is my last Presidential column of my term. I would like to express my gratitude to "I hope that SEPI the members of SEPI for being a part of this international organization and representing can make the best out voices of SEPI around the globe. I am grateful to Tracy Prout, the chair for Communication and Publications Committee, who renovated our webpage, created our of the current new logo, Instagram and twitter accounts to connect us better. I would like to thank Alex Vaz who has served as the editor for our newsletter and helped us connect challenge to cultivate throughout a year. This is the last edition for which he serves as editor. and develop some of I am grateful for the SEPI executive Committee as well as the Advisory Board chaired the important by Marv Goldried and Paul Wachtel. Their wisdom and support helped us keep this trademarks of SEPI: organization going. A special thanks to our dedicated administrative officer, Tracey Martin. Finally, I am grateful for representatives of the SEPI Committees. They have our dialogue, worked hard to improve our experience as SEPI members and help the organization collaboration and grow.
rewarding collegial I am grateful for this opportunity to serve as SEPI’s 2020 President. I am full of relationships among renewed commitment and appreciation for SEPI. I look forward to seeing you on our next webinars and future meetings. its members." Shigeru Iwakabe n n
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n SEPI Welcomes Ukranian Regional Network !
We have just welcomed a new Regional Network from Ukraine. The coordinator is Dr. Olha Lazarenko. Ohla writes that she would like to interest both students, practicing psychotherapists of all disciplines, and researchers in the activities of the SEPI community. Another goal is to encourage knowledge of other cultures, and scientific activity. Olha is a member not only of SEPI, but also of SPR and APA. She does research and clinical practice, and has a number of publications. As with all applications, the Ukranian application was reviewed by Tom and Doménica, by the current RN coordinators, and by SEPI’s Executive Committee, with strong support from all. Our Regional Networks come from over 20 different countries, Olha Lazarenko and show the universal importance of psychotherapy integration.
n Tom Holman ([email protected]) Doménica Klinar ([email protected])
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Arnkoff-Glass Regional Network of the Year Award 2019 n By Ueli Kramer, University of Lausanne, Switzerland
The Swiss Network of SEPI is very honored to be selected for the Arnkoff-Glass Regional Network of the Year Award 2019. In this report, I will describe some of our recent activities in Switzerland. "The Swiss The psychotherapy landscape of Switzerland is marked by a heterogeneity in practice, a favorable context for research, supported by a federalistic and decentralized, political system. The latter Network of yields 26 different health systems on a surface smaller than 50.000 square kilometers, with approximately 8.5 million inhabitants speaking four different languages. So services in mental SEPI is very health, provided mainly by psychiatrists and psychologists, may be quite diverse across a small honored to be country, in response to varying contextual factors. Accordingly, the exploration of psychotherapy integration may vary in its focus, depth, method and yield across the country. Like the different selected for tastes of exquisite pralines, Swiss psychotherapists in different corners of the country may be practising very differently – generally on a high level of competence –, and they may be receiving the Arnkoff- quite different psychotherapy trainings, also generally on a high level of quality and structure. What may be missing at times is a context which brings these different practices together with the Glass aim of even increasing their effectiveness. A mindful therapist may be asking: what should I do with this particular client when the interaction gets difficult? Has any other colleague had Regional experience with such a particularly difficult situation? What does psychotherapy research has to say? The exploration of psychotherapy integration may offer tentative answers to these questions. Network of While research tends to cut across the singularities of specific therapy approaches, trainings contexts, and delivery methods, it remains a challenge to integrate, in this heterogeneous context, the Year psychotherapy practice with research. Award Yet, this is what many Swiss SEPI members are striving to do. Combining the excellence of research with the relevance of clinical practice has been a credo for many Swiss SEPI goers for 2019." years, and by the way, this is true not only for members from Switzerland! I will report on two recent events which represent this challenge in a nice way. In February 2019, we have co-organized with the Swiss Society for Emotion-Focused Therapies (EFT-CH), the Swiss-French branch of the European Federation of Psychoanalytic Psychotherapy (EFPP), the Swiss Society for Psychoanalysis (Lausanne Center), and the University Clinic of Lausanne a clinical debate on memory reconsolidation in psychotherapy. Featured speakers were Richard D. Lane for the main talk, and Catalina Woldarsky Meneses and Gilles Ambresin for the clinical illustrations from two different perspectives. The model presented by Lane et al. assumes n that long-term memories are not only passive records of the past, but also blueprints for future interpersonal transactions.
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Under certain circumstances, memories may be updated and changed with new information. This process takes place within a co-activation of episodic and semantic memory structures, along with the essential activation of emotion, substantiated in a neuronal basis implying the hippocampus, the amygdala and specific pre-frontal areas. This hypothesis may be true across psychotherapy approaches. Our two discussants were able to illustrate with clinical material the process of memory reconsolidation from psychodynamic and emotion-focused perspectives. A convincing exploration of a common basis of how psychotherapy works!
In October 2020, together with our Austrian and German SEPI colleagues Markus Boeckle and n Johannes Ehrenthal, the Swiss Regional Network co-organized a one-day symposium on deliberate practice in psychotherapy, in German, with an important line-up including (among others) Silke Gahleitner, Franz Caspar, René Reichel and Astrid Riehl-Emde. It was planned to be held in Bregenz "The Swiss (Austria, right at the corner of the three German-speaking countries), but due to the pandemic, it was Regional held online. With this symposium, supported by SEPI, deliberate practice has arrived in the German speaking world as a productive way of enhancing diverse psychotherapy trainings, focusing on the Network is knots and bolts of the therapist effect in psychotherapy, and taking integrative principles of change into account in the training and supervision of psychotherapists. We spent an inspiring day together, currently and many questions were debated on the characteristics of the development of expertise in psychotherapy through repeated and informed deliberate practice. The implementation of deliberate working hard practice in different contexts (couple’s therapy, emotion-focused therapy, trauma therapy, supervision, animal-assisted therapy, online counseling) was discussed. As an example in Switzerland, deliberate on bringing us practice may inform the debate on the still lacking overall reimbursment policy of psychological all together psychotherapy with the underlying issue of a truly competence-based psychotherapy. next year at the 37th SEPI (from left to right) Ueli conference to Kramer, Richard Lane, Catalina Woldarsky be held in Meneses, Gilles Ambresin in February 2019 in Lausanne Lausanne (Switzerland). (Switzerland), from June 10th to 12th, 2021." Last but not least, the Swiss Regional Network is currently working hard on bringing us all together next year at the 37th SEPI conference to be held in Lausanne (Switzerland), from June 10th to 12th, 2021. We hope these topics may be discussed, along with many others under the conference theme of «Working with emotion in psychotherapy: clients, diagnoses, methods». While the current health context seems more threatening than reassuring, the conference organizing committtee wants to reassure you that we do everything possible to deliver this conference in one or the other format. For suggestions or questions related to the 2021 SEPI conference, please contact us at n [email protected], or the conference chair Dr. Alberta Pos [email protected]. n
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Join Us For Our Next Free Webinar!
"Working with Emotions in Therapy the EFT Way" A Fireside Chat with Les Greenberg, Rhonda Goldman, & Alberta Pos Tuesday, December 15, 2020 7:00 - 8:30 pm (Eastern)
How can we, as therapists, work effectively with emotions in therapy? In this free-format conversation about emotion in psychotherapy. Drs. Greenberg, Goldman & Pos, trainers in the Society of Emotion- Focused Therapy (ISEFT) will engage in discussion on how we can target the emotions of our clients in a principled, yet integrative, EFT way. Opening the discussion, Alberta Pos, the incoming SEPI President and Program Chair of SEPI's Annual Meeting in Lausanne, will introduce the conference theme and describe how broadly emotion work in therapy can be conceived. Following this, Les Greenberg will introduce how integrative EFT treatment offers guidance for clinicians to work emotionally with many populations. He will also discuss new research that offers clinicians new perspectives on working with emotion. Dr. Goldman, is past SEPI President and co-author of several volumes relating to EFT in general and also writes about couples work in EFT. She is also an expert on interpersonal issues related to emotion and how to help couples co- regulate their affect through working with maladaptive emotional patterns. Finally, Dr. Pos will discuss recent research that highlights the importance of emphasizing emotion skills and emotional intelligence with our clients. Audience participation and questions will be encouraged.
REGISTER HERE
Les Greenberg Rhonda Goldman Alberta Pos
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Improving therapy effectiveness through reliable, personalized case formulation
David Kealy, University of British Columbia George Silberschatz, University of California at San Francisco
Through welcoming contributions from different therapy models, psychotherapy integration offers multiple pathways n to personalizing treatment according to individuals’ goals, needs, sensitivities, and preferences. In practice this is facilitated by a relatively coherent framework––for each particular patient––that can be used to guide the therapist’s "Clients show understanding, interventions, and attitudes. In this article we briefly describe a case formulation framework known as the signs of Plan Formulation Method that has been developed, David Kealy empirically tested, and refined over several decades by immediate members of the San Francisco Psychotherapy Research Group (https://www.sfprg.org). progress when Plan formulation refers to the development of a set of hypotheses about what a particular client is trying to therapists accomplish, overcome, and master through psychotherapy–– as well as tentative ideas about the ways in which they may intervene in work with the therapist. Research has demonstrated that plan formulations can be made reliably, and that clients show ways that are signs of immediate progress when therapists intervene in George Silberschatz ‘plan ways that are ‘plan compatible’ (Silberschatz, 2005). Moreover, therapists’ plan compatibility has been found to predict improvement over the course compatible’." of therapy (Silberschatz, 2017). It is important to note that working according to the client’s ‘plan’ can potentially involve the use of interventions and techniques from across different orientations and approaches. Developing reliable plan formulations rests upon several key assumptions of Control-Mastery Theory (CMT; Weiss, 1993). CMT is an integrative relational cognitive-dynamic theory that seeks to understand and explain the therapeutic process––in light of idiosyncrasies and differences across clients––rather than prescribe interventions a priori (for an overview, see Silberschatz, 2005). The following basic assumptions of CMT support the Plan Formulation Method: 1. Adaptation is a fundamental human motivation; n 2. Children’s efforts to adapt to inimical circumstances (i.e., trauma) may involve the development of ‘pathogenic beliefs’ about themselves, others, and the world; 3. When people seek therapy, they are typically doing so to overcome pathogenic beliefs that interfere with their pursuit of adaptive developmental goals;
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4. Clients in therapy are typically highly motivated to overcome pathogenic beliefs and achieve their goals, and may work in idiosyncratic ways to do so; 5. Safety is an important determinant of the degree to which clients can regulate (i.e., control) their mental functioning and perform psychological work to achieve their goals (i.e., mastery). n Plan formulation attends to the ways in which the client attempted to adapt to traumas through developing pathogenic beliefs, the ways in which these beliefs impede achievement of personal goals, and potential means for creating safety and corrective experiences to address pathogenic beliefs. After obtaining a history of the client’s difficulties and personal development, the therapist can organize inferences about the "After plan according to the following plan components: Goals, Obstructions, Traumas, Insights obtaining a & experiences, and Tests (GOT IT). Goals refer to the client’s adaptive developmental goals, that is, goals for therapy and for history of the life more broadly. It is often helpful to consider the client’s stated goals whilst being aware that sometimes a client may state a maladaptive goal that actually reflects a client’s pathogenic belief. In other instances, clients may not feel safe enough to become consciously aware of their adaptive goals. Thus, the therapist must infer goals based on difficulties and an understanding of the client’s history, abilities, and life circumstances. personal Obstructions refer to the obstacles that prevent the client from pursuing or achieving adaptive goals. Typically these are considered in terms of pathogenic beliefs, which the development, therapist may need to infer from the client’s presentation and history. Pathogenic beliefs originally develop to facilitate adaptation to difficult interpersonal circumstances, when the therapist children must preserve attachments to parents. A child may, for example, adapt to maltreatment by believing she deserved to be treated badly, thereby preserving an image can organize of a benevolent parent. During adulthood, this pathogenic belief may fuel poor self- esteem and lead to unsatisfying relationships. Another child may infer that being inferences separate will abandon or offend an insecure parent. This pathogenic belief may subsequently inhibit autonomous functioning and lead to excessive guilt and about the responsibility for others. plan." Traumas are considered broadly as experiences that interrupt the safety and capacity for pursuing developmental goals. Generally, an experience may be considered traumatic if it led to the development of pathogenic beliefs. Informed by knowledge of psychosocial development, therapists may need to infer potential traumas, as some clients may not feel safe enough to disclose them. Insights & experiences refer to the kind of knowledge and learning the client may need to obtain during therapy to feel safe, address pathogenic beliefs, and master traumas. This encompasses both verbal, declarative knowledge and experiential, procedural knowledge. In other words, benefit may occur through verbal interventions––promoting new learning n about the origins and functions of pathogenic beliefs––and from therapists’ attitudes and behaviours that constitute corrective experiences for that particular client.
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Tests are trial actions or scenarios used by the client to acquire a sense of safety and disconfirm pathogenic beliefs. According to CMT, clients test the veracity and appropriateness of their pathogenic beliefs within the therapy relationship. Testing is typically performed unconsciously to learn about and develop alternatives to the pathogenic beliefs that constrict the pursuit of important developmental goals. While testing, the client observes the therapist’s attitudes and responses to determine whether it n is safe to proceed in becoming aware of and pursuing forbidden goals. If the therapist appears supportive of the client’s effort to disconfirm pathogenic beliefs, the client is helped toward resuming adaptive personal development. For example, a client may test by proposing a reduced frequency of sessions––‘hoping’ that the therapist will not agree "There is no with this proposal and thus undermine his belief that he doesn’t deserve care and ‘one size fits all’ attention. Another client may become argumentative with the therapist to test a pathogenic belief that disagreements are intolerable. Yet another client may diminish her in accomplishments to test whether others need her to be subordinate. Understanding how such scenarios reflect a particular client’s adaptive therapeutic work, and what kinds of psychotherapy, responses would be optimal, is greatly facilitated by a plan formulation. There is no ‘one and the Plan size fits all’ in psychotherapy, and the Plan Formulation Method provides an elegant framework for integrative, personalized intervention. Formulation Method References Silberschatz, G. (2005). Transformative relationships: The control mastery theory of provides an psychotherapy. New York, NY: Routledge Press. elegant Silberschatz, G. (2017). Improving the yield of psychotherapy research. Psychotherapy framework for Research, 27, 1-13. Weiss, J. (1993). How psychotherapy works. New York, NY: Guilford Press. integrative, personalized intervention." n The Integrative Therapist: Call for Content
The Integrative Therapist wants you to be an author. We are seeking brief, informal, interesting and actionable articles with a personal touch. Please limit references to those that are absolutely essential. Our bias is towards articles relevant to SEPI’s three missions: integration between researchers and clinicians, integration across cultures, and further devel-opment of psychotherapy integration. Contributors are invited to send articles, interviews, commentaries and letters to the Newsletter's Editor at: [email protected]
Submission Deadlines and Publication Dates January 1 deadline for February Issue April 1 deadline for May Issue July 10 deadline for August Issue October 15 deadline for November Issue
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The race to transforming mental healthcare through cutting edge technologies: Are you on board?
By Ioana Podina Senior Assistant Professor, University of Bucharest (UB), Romania Chair of the SEPI Research Committee
There has been a lot of turmoil around n advancing the research on digital mental health solutions (DMHS) and rushing its uptake in clinical practice in the context of the COVID-19 pandemic. If anything, the current COVID-19 pandemic made it clear that we need viable "Digital technological alternatives for instances where in-person treatment becomes unavailable. phenotyping Though the current COVID-19 pandemic is a powered by AI good template for this article’s topic, there is no need to give it more hype than it has already received and therefore it shall be referred to as “He who shall not be named” (sic) in the and machine following. learning The rapidly growing interest for DMHS and future prospects The global digital health market is predicted to more than double its value by 2024 (Market forecasts Data Forecast, 2020; www.marketdataforecast.com) and in its rise, it will push forward mental healthcare solutions. It took almost 20 years for internet-based DMHS to be embraced by probably the practitioners in most countries. This will most likely not be the case in the future. In other words, the combination of the fast pace of technology, the aggressive marketing interests, and best how mental the increasing receptiveness of users in regards to readily available solutions means that mental healthcare is transforming whether we - as mental health specialists - are on board or healthcare will not. look like in the Out of all the future technological prospects, digital phenotyping powered by AI and machine learning forecasts probably the best how mental healthcare will look like in the nearby future. nearby future." Digital phenotyping stands for moment-by-moment tracking and assessment of the individual- level data that is automatically generated and collected from personal digital devices, such as smartphones and wearable sensors. Below, are some of the clinical and public health uses of digital phenotyping powered by machine learning and AI (more details in Podina & Caculidis, in press). Firstly, tracking data can be highly suitable for forecasting and preventing relapse. Relapse prevention is chiefly important in mental illnesses such as schizophrenia and borderline personality disorder (BPD). The development of digital phenotyping tools that deliver timely n warnings to BPD or schizophrenia sufferers would be highly useful as they find it difficult to self-monitor. Patient behavior anomalies days before a relapse could be used to inform machine learning algorithms and develop smarter digital phenotyping tools.
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Secondly, continuous data collection is expected to enable the identification of undiagnosed conditions and/or lead to a susceptibility analysis. Passive detection of phone activity (e.g., GPS tracking) and machine learning is by now used to detect individuals at risk for depression or anxiety. Previous research has also demonstrated the feasibility of machine learning algorithms for natural language processing in training predictive models using Twitter and Facebook content and activity records (Eichstaedt et al., 2018). This could mean that the automatic natural language processing of social media posts will become a progressively more accurate screening method. Thirdly, another important usage of digital phenotyping is that of tracking treatment growth and treatment choices. Only around half of the depressed patients respond to their first selected n medical treatment choice (Rush et al., 2009) with significant time and money resources directed to finding the next best option. Digital phenotyping could reduce these costs by timely tracking user progress and giving access to the level of intervention they require in a stepped care manner (e.g., the Aifred project - www.aifredhealth.com). "We need to Overall, digital phenotyping - in the context of machine learning and AI - is estimated to impact care at all stages stemming from prevention to intervention. Other noteworthy mentions that are consider set to drive progress in mental healthcare are conversational agents or chatbots, sensors and whether we – as integrated systems, and big data analytics (here are some present-day projects; Exploring and Modifying the Sense of Time in Virtual Environments; www.virtualtimes-h2020.eu; European mental health Platform to Promote Wellbeing and Health in the Workplace; www.empower-project.eu). Warranted caution specialists - Therefore, as mentioned before, we need to consider whether we – as mental health specialists - board a train board a train that holds the promise to be a fast pacing train with no stops. Yet, why most of us aren’t on board yet? that holds the (1) The majority of the current DMHS solutions have been disappointing at best. Indeed, there are several systematic reviews and meta-analyses which end on a positive note, including some promise to be a earlier work (Podina et al., 2015). Yet on a closer look, when looking at its efficacy against separate control groups, and not against an overall control grouped encompassing mostly fast pacing train waitlist groups, DMHS solutions do not seem to be an alternative to in-person interventions with no stops." (Fodor et al., 2019), and these result tends to resurface in other fields of healthcare as well (Podina & Fodor, 2018). On the upside, DMHS options perform well when guided or when preceding or accompanying standard care. For instance, Duffy et al. (2020) recently researched a stepped care model for severe depression and anxiety using internet-delivered Cognitive Behavioral Therapy (iCBT) as a prequel to in-person intervention. The results supported the use of iCBT as a means to reduce treatment delivery waiting times and enhance clinical efficiency. (2) The second argument is very much connected to the first. There is little funding directed towards improving DMHS solutions and directed at mental health research overall (see n www.treat-me.eu/dissemination/official%20documents/white-paper.html). Take for instance the case of serious games. The gaming industry is making groundbreaking steps towards adaptive games that are responsive to a user’s digital input and that are incredibly immersive, yet serious games with therapeutic relevance are facing difficulties to be interactive and immersive due to limited funding.
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(3) On account of the 2nd point, DMHS solutions tend to have a high attrition rate and due to the repetitive nature of the tasks they reach a point of limited usage within weeks. With the new surge of interest in regards to mental health, it is only a matter of time since private funding entities and major players in the IT industry will shape how DMHS will look in the future. Hence, from a technological standpoint, there is no rationale for which to wait another 20 years to go by for practitioners to embrace today’s technological advancements. The biggest concern is that this fast pace of development will disregard research in order to rush the product to a marketing stage. The question is (a) whether professional and national funding bodies and researchers alike will join the race set by technical advancements and seek new ways and regulations to speed-up the research – user uptake process or (b) will approach it cautiously n risking for the untested product to reach the prospective patient faster. Nevertheless, this final argument should not be confounded with eagerness to readily translate preliminary research into practice, but rather as an awareness statement to bridge the gap between digital innovation and day-to-day practice. "I expect that the biggest leap in mental My take on what to expect in the next 30 years Considering that it took approximately 20 years for internet delivered interventions for mental health will be health to be embraced by psychotherapy in most countries, I do not expect that by 2050 mental health specialists will be a dying breed. On the contrary, human interaction may be all the more made in regards needed in a context where most aspects of life will be digitalized. I do expect, however, that technological advancements, particularly AI, will shape how mental healthcare looks like in the to how accurate future. Hence, there should be more individuals timely diagnosed, more efficient accessible self- help preventive solutions, and early detectable and reliable markers of at risk individuals that our behavioral push forward notifications and timely solutions. I expect that the biggest leap in mental health will be made in regards to how accurate our behavioral prediction algorithms will be which will prediction leave more room for preemptive actions and hopefully not for Minority Report Scenario. Most importantly, due to mass digitalization, concern for mental health should become in the future 30 algorithms will years like a mental fitness mindset which is recurrently exercised and just a hologram away from be." a mental health trainer. Briefly, I expect that we will continue on the track that we are already on and the pace at which we will choose to embrace new technological developments will have ups and downs. n n
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Daring to engage: Can we bring psychotherapy research closer to the complexity of human nature?
By Sasha Rudenstine & Talia Schulder City University of New York, USA
How can we empirically capture the complexity of human nature and the intertwining variables that n make psychotherapy helpful (or unhelpful)? Psychotherapy research is deeply challenging, yet in spite of the challenges, the depth of our knowledge is profound and is a testament to the efforts of many who have approached the work "It is essential with nuance, compassion, sophistication, and that our flexibility. The world of psychotherapy research was born out of a wish to amount empirical research evidence for a talking-based treatment of mental illness. For decades prior, support for psychotherapy was limited to theoretical discussions and case studies. Empirical work address more that unfolded in the years since, aimed to (i) understand, through quantitative, qualitative, and mixed methodological approaches, which factors contribute to patient focally the change over the course of psychotherapy and (ii) test the efficacy of specific treatment approaches (i.e. evidence-based treatments). Nevertheless, the nature of research diversity of our design, sample size, and statistics often force us to examine one or two key variables at a time, which, as many of us would agree, oversimplifies the experiences of patients in patients and treatment and the range and interactive complexity of processes that account for change. Moreover, and at least as serious, it is essential that our research address more focally their the diversity of our patients and their experiences in treatment. As a field we need to broaden and deepen our focus by considering more fully the diversity of life experiences experiences in and social locations across patients as well as across therapeutic dyads. Rather than ask about the role of working alliance in psychotherapy, for example, we can test if working treatment." alliance functions the same for all patients and dyads, and if not, how it varies.
Another under-examined dimension of psychotherapy research relates to therapists themselves, who are frequently left out of research studies. To the extent that therapists participate in research, they are often used as reporters for their patients’ functioning and for the therapeutic process (i.e. working alliance or techniques employed), or simply included via demographics, such as therapist gender, race, ethnicity, within a broader study. In fact, to the best of our knowledge, there is little work that examines n therapists’ own psychological profiles independent of their patients, such as their level of mindfulness, attachment categorization, personality organization, or emotional intelligence and the relationship between these therapist factors on treatment course and patient outcomes.
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As a field we are reluctant to define clinicians as “good” or “bad” through quantitative metrics. To do so would force a dichotomy that glides over the complexities of the therapeutic process, waters down the web of factors that make a therapist effective, and neglects ways in which this efficacy shifts depending on the specificities of the patient and patient/therapist dynamic. Still, our hesitance as therapists to become more vulnerable to scrutiny by participating in psychotherapy research, we fear, will create an artificial barrier against further inquiries into psychotherapy.
Our framework is grounded in a two-person model of treatment that holds at its center the intersection of patient and therapist factors, and emphasizes social location and one’s n experiences over the life course. It is our opinion that research too often does not reflect this orientation and therefore undervalues how our patient’s lifetime experiences affect how they may progress through treatment. Working alliance, a vital and much-examined construct in "Further psychotherapy research, hones in on the relationship, however this relationship is often conceived of as independent of the variety of other patient and therapist constructs that may investigations are moderate it. For example, cultural humility, a newer and less popular area of study, relative to working alliance, places an increased onus on the therapist to acknowledge their bias and necessary to form assumptions about their patient’s lived experiences and held identities. In this vein there is adequate and growing evidence that cultural humility may contribute significantly to working alliance, especially among patient-therapist dyads that do not share the same social-location(s) and/or realistic reference group memberships. Further investigations are necessary to form adequate and realistic understandings of why certain treatment processes and certain therapists, themselves, understandings of are more effective than others and to better understand for whom these processes and therapists why certain are more effective. treatment To address the above, three questions guided the development of the Programmatic Evaluation and Clinical Effectiveness (PEACE) program and the ongoing approach to the data (PI: processes and Rudenstine, for more information visit: www.intersectccny.com). certain therapists, For whom does psychotherapy work? themselves, are Psychotherapy has the potential to be effective for anyone. Nevertheless, the underlying assumption here is that psychotherapy is at its best when clinicians consider who their patient is more effective at the onset and tailor treatment to meet patient needs, rather than fitting every patient into the than others." same treatment frame. What are the mechanisms by which it works? There are a handful of constructs that have been repeatedly identified as catalysts of change in psychotherapy. While the work on these constructs must continue, we recognize that these constructs explain a very small amount of the variance associated with treatment outcomes. Two avenues of inquiry that we believe are warranted are (i) an examination of additional constructs as potential mechanisms of change, and (ii) an expansion of the current work to test if the n variance in treatment outcomes changes across different subpopulations or other psychological profiles. A core assumption here is that the strength of each mechanism of change may vary by patient, by therapist, and by dyadic combination.
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What do we mean by “work”? Research that defines successful outcomes by symptom alleviation, for example, may capture positive or negative change among individuals who present to treatment symptomatically, but may miss the quality of change occurring in an individual attempting to negotiate a career change in their treatment. Patient reported treatment goals are informative data that can be used to examine psychotherapy subpopulations. For example, we have coded patient reported treatment goals into 6 categories and have found, unsurprisingly, that patients who report a psychiatric goal (i.e. reduce anxiety) have significantly higher symptom levels as measured by the Brief Symptom Inventory than individuals who report an intrapersonal goal (i.e. work on self-confidence). Given this finding, it would be misleading to assume the same outcome can n measure effective psychotherapy for these two subgroups.
These questions are the foundation from which the PEACE program that was launched in 2015 at The Psychological Center through the Intersect Lab at The City College of New York. For the "By daring to past five years, we have sought answers to some of these questions, with the goal of applying the psychotherapy research paradigm to a community-based setting with a broad racial and engage the ethnic diversity among patients and therapists, and a plethora of presenting problems, psychological profiles, and therapist variables. As a part of a doctoral program training clinic, complexities to we approach treatment planning and conceptualization with the flexibility and openness that accompanies training clinicians. Our research model is based in four-month follow up which we have assessments, and the long-term nature of the treatment that our clinic offers contributes to the nuanced questions that we can both ask and attempt to answer. This model, understandably, is been alluding not feasible in many contexts, but our aspirations and questions that aim to explore the complexity of treatments can be applied universally. in this piece, The integrated model of SEPI, and the flexibility with which each of us approaches different treatment modalities, allows for inquiries that consider the interactions across a variety of we believe that treatment variables and that more fully address the complexity with which clinicians operate, which is rarely captured in the research that has been conducted to date. To be sure, many we can make nuances and realities of therapy will always evade study, but by daring to engage the complexities to which we have been alluding in this piece, we believe that we can make real real progress." progress in getting even closer to them. References Anderson, T., Ogles,, B.M., Patterson, C.L., Lambert, M.J. and Vermeersch, D.A. (2009), Therapist effects: facilitative interpersonal skills as a predictor of therapist success. Journal of Clinical Psychology., 65: 755-768. https://doi.org/10.1002/jclp.20583 Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75(6), 842–852. https://doi.org/10.1037/0022-006X.75.6.842 Don-Min Kim, Bruce E. Wampold & Daniel M. Bolt (2006) Therapist effects in psychotherapy: A random-effects modeling of the National Institute of Mental Health Treatment of Depression Collaborative Research Program data, Psychotherapy Research, 16:2, 161-172, https://doi.org/10.1080/10503300500264911 n Goldberg, S. B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W. T., Whipple, J. L., Miller, S. D., & Wampold, B. E. (2016). Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice. Psychotherapy, 53(3), 367–375. https://doi.org/10.1037/pst0000060 n
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The Experiential Revolution
By Giancarlo Dimaggio Center for Metacognitive Interpersonal Therapy, Rome, Italy
Times are changing in the world of n psychotherapy. Over the last 15 years, empirically supported treatments are more and more including experiential practices, which in the past "Empirically were mostly confined to non-empirically supported orientations. If you had asked your supported best friend in your psychotherapy school about guided imagery and rescripting, two-chairs, role- treatments are play or experiencing vivid, painful scenes while making the patient follow your fingers or while tapping on their legs, she would have more and more answered: “I have heard they exist, somewhere”. And if she did know them, she sure was not enrolled in either a cognitive or a psychodynamic training. Chances are she was including into a humanistic school, gestalt-oriented, or some psychodrama. And, with some exceptions, neither gestalt nor psychodrama could be labelled under the category of experiential scientifically based psychotherapies. So, if you were a self-defined ‘serious’ therapist, your sessions with your patients were all about talking. Unless you were a behavioral practices, which therapist, so you gave them exposure exercises, or you learnt hypnosis which, honestly, in the past was a scientific practice long before its pupil, i.e. EMDR. Well, hypnosis together with emotion-focused therapy (EFT; Greenberg, 2002) and were mostly prolonged exposure for PTSD (Foa et al., 2007) were almost the only two practices which: a) were based on a empirically testable paradigm and b) included experiential confined to work, meaning asking patients not just to remember problematic episodes, associate from those, reason differently about those, but also to re-live them in the here and now non-empirically of the session. supported What is happening now? Let me mention a series of empirically supported treatments, beside the aforementioned hypnosis and EFT: compassion focused therapy (Gilbert, orientations." 2010), schema-therapy (Arntz & Jacob, 2012), EMDR (Shapiro, 2001), dialectical behaviour therapy for complex trauma (Bohus et al., 2020) and metacognitive interpersonal therapy (Dimaggio et al., 2020). Are they all empirically supported or aiming at empirically support? Yes, they are, but what do they share? They share a large use of experiential techniques: role-play, guided-imagery and rescripting, two-chairs, bodily work. This means, that if you are at the café with your best friend during the psychotherapy n training today, and a colleague of another orientation meets you and asks if you have ever heard of those techniques, you and your friend are now more likely to answer in chorus: “Yes, we do!”.
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Why is this happening? I can tell what I witnessed over the last 25 years. First, the empirically supported movement was mostly about CBT. And CBT therapists mostly talked, unless when delivering behavioral homeworks. Their main rival was the family of dynamic therapies and sure the latter folks only talked with their clients, and cared very little about empirical testing. With time, empirical support grew for many modalities, and psychodynamic therapies jumped on board. With empirical support came the awareness that success was always limited: the percentage of dropouts, non-responders and partial responders was significant, and relapse was a serious issue. So, therapists willing to deliver something backed up by science realized their n work was insufficient, albeit for the majority of their patients. Second, interest in treating severe clients, like one with personality disorders and complex trauma, grew and again it become a matter of empirical investigation. Clinicians in this area knew "A revolution since decades that promoting change in these persons was difficult. So, with a more and more tactful regulation of the therapy relationship, they were more able to limit dropouts, but many happened because therapies stalled. DBT, I have to acknowledge, was a game changer in that domain. It included a of ... growing heavy behavioral element when treating borderline personality disorder, and it made clear that in order to change, these patients had to do something actively. impact of the The third driver of what I am naming ‘the experiential revolution’ is a change in theory. empirically Developmental psychology, neurosciences and experimental psychopathology consistently showed that the largest part of maladaptive cognitive-affective processes unfold themselves at a supported therapies level which you may name: implicit, tacit, procedural, unconscious (e.g. Bargh, 2017). Patients movement; suffer not just for their maladaptive conscious attributions about self and others, but because of learnt patterns involving behavioral procedures, implicit attributional biases and quick and growing interest in intense somatic responses involving hyper- or hypo-arousal. therapies of Summarising, to my view such a revolution happened because of the combination of these 3 factors: a) growing impact of the empirically supported therapies movement; b) growing interest patients with more in therapies of patients with more severe pathology; c) advancement in basic psychological and severe pathology; neuropsychological sciences. But the revolution did not come for free, knights of old-fashioned schools raised their barriers, advancement in launched their anathemas to the revolutionaries. Their main argument was a concern about basic psychological safety: experiential techniques are risky, if you use them you are likely not respecting the subjectivity of your clients and their need to be empathically listened. Some considered and introducing these practices (e.g. behavioral experiments; Gaylin, 2000) as intrusive. Giving that neuropsychological most of these techniques have the primary effect to let patients’ arousal mount, concerns about safety were expressed with sentences like: “They risk dysregulation”, “They will end up out of sciences." their window of tolerance”, “They will dissociate”. Then a more basic criticism: in light of the Dodo verdict, we know that common factors are what you need to play a good game and therefore: why the need to add these “risky” paraphernalia to your toolbox? These criticisms come to a cost, that is they ignite fear and limit dissemination of experiential practices in psychotherapy. The most striking example is what happens to a heavily experiential treatment, that is prolonged exposure for PTSD (Foa et al., 2007). It has very solid empirical support, but its implementation is largely insufficient (Cahill et al., 2006). As Cahill and colleagues note, among the reasons for insufficient dissemination are concerns that patients will n decompensate. Spoiling the finale of my café story: the two friends sipping their espresso know
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experiential techniques, but at least one of them does not apply them. And who knows if the other does? One may sceptically ask: is there ground to say that experiential therapies are both safe and more effective than talk therapies? Here I have to acknowledge that the question is not solved once and for all. We have not sufficient ground to say that these experiential-based and empirically supported therapies are faster, more powerful and equally safer to non-experiential therapies. The Dodo may still hoover in the air, in spite of its inability to fly. But data are growing backing up these ideas. I will only report a few examples. Tripp and colleagues (2020) found that exposure did not exacerbate symptoms in a trial on patients with n PTSD. In a trial of DBT vs Cognitive Processing Therapy for women with complex trauma, the DBT arm was exposure-based unlike the CPT one. The DBT arm had less dropouts (25% vs 39%) and better symptom response. No concerns about safety could be raised from this study and no Dodo flying in the air, DBT clearly outperformed CBT, non-exposure based. Of note, do "We need to not think that exposure therapies ignore the issue of safety. Bohus and colleagues (2020) pay plenty of attention to that, and exposures only starts by session 17-20. But let see that from the work hard in other angle: even with a very severe population, therapists did not wait more than 5 months to start with exposures. testing these Another study compared two experiential-based therapies for adults with childhood trauma: Imagery Rescripting vs EMDR (Boterhoven de Haan et al., 2020). It is a population with intense ideas, before suffering and, according to theory, with some difficulties in trusting therapist on the ground of their developmental history. Well, dropouts were very low in both groups (7.7% overall), again concluding that indicating that treatment was safe and well-tolerated. Treatments were equally effective on all experiential outcomes, not surprisingly as they shared many similarities. In Metacognitive Interpersonal Therapy the experiential element is fundamental, a combination of role-play, imagery rescripting psychotherapies and bodily work. Preliminary studies had very low dropout rates and good outcomes (Dimaggio et al., 2017; Gordon-King et al., 2018; Inchausti et al., 2020; Popolo et al., 2019). will be more Finally, a couple of studies on the psychotherapy process are promising. Stiegler and colleagues (2018) have found that anxiety and depression changed more in their sample after the two-chair than the new techniques was used, than during the first sessions which were only focused on alliance building, empathic attunement to affect and other common factors. Similarly, Romano and sensation." colleagues (2020) investigated a sample with Social Anxiety Disorder. Clients were randomly assigned to 3 conditions, a single sessions of a) imagery rescripting (IR) b) imagery exposure (IE) c) supportive counselling. Only the two imagery-based conditions yielded changes in memory details, which were absent at all in supportive counselling. Are these studies enough to say that the revolutionaries are right, that therapists in the future have to be and will be trained in using experiential techniques, as they are safe and more powerful? Such an answer is premature. And I have to say that some heavily experiential therapies, like sensorimotor therapy (Ogden & Fisher, 2015) and coherence therapy (Ecker et al., n 2012) lack empirical support at all. We need to work hard in testing these ideas, before concluding that experiential psychotherapies will be more than the new sensation, and we eventually have empirically evidence backing up what evolution said 400 years ago: the Dodo is extinct, with good reasons.
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References Arntz, A., & Jacob, G. (2012). Schema therapy in practice: An introductory guide to the schema mode approach. Wiley. Bargh, J. A. (2017). Before you know it: The unconscious reasons we do what we do. Simon & Schuster. Bohus, M., Kleindienst, N., Hahn, C., et al. (2020). Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT- PTSD) Compared With Cognitive Processing Therapy (CPT) in Complex Presentations of PTSD in Women Survivors of Childhood Abuse: A Randomized Clinical Trial. JAMA Psychiatry. Advance online doi:10.1001/jamapsychiatry.2020.2148 Boterhoven de Haan, K., Lee, C., Fassbinder, E., Van Es, S., Menninga, S., Meewisse, M., . . . Arntz, A. (2020). Imagery rescripting and eye movement desensitisation and reprocessing as treatment for adults with post- traumatic stress disorder from childhood trauma: Randomised clinical trial. The British Journal of Psychiatry, n 217(5), 609-615. doi:10.1192/bjp.2020.158 Cahill, S.P., Foa, E.B., Hembree, E.A., Marshall, R.D. & Nacash, N. (2006). Dissemination of exposure therapy in the treatment of posttraumatic stress disorder. Journal of Traumatic Stress, 19, 597-610. https:// doi.org/10.1002/jts.20173 Dimaggio, G., Salvatore, G., MacBeth, A., Ottavi, P., Buonocore, L. & Popolo, R. (2017). Metacognitive Interpersonal Therapy for personality disorders: A case study series. Journal of Contemporary Psychotherapy, 47, 11-21. DOI: 10.1007/s10879-016-9342-7 Dimaggio. G., Ottavi, P., Popolo, R. & Salvatore, G. (2020). Metacognitive Interpersonal Therapy Body, imagery and change. Routledge. Ecker, B., Ticic, R. & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. Routledge. Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences –Therapist guide. Oxford University Press. Gaylin, W. (2000). Nondirective Counseling or Advice? The Hastings Center Report, 30(3), 31. Gilbert, P. (2010). Compassion focused therapy: The CBT distinctive features series. Routledge. Gordon-King, K., Schweitzer, R.D. & Dimaggio, G. (2018). Metacognitive Interpersonal Therapy for Personality n Disorders Featuring Emotional Inhibition: A Multiple baseline Case Series. Journal of Nervous and Mental Disease, 206(4), 263-269. doi: 10.1097/NMD.0000000000000789 Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work with their feelings. American Psychological Association. Inchausti, F., Moreno-Campos, L., Prado-Abril, J., Sánchez-Reales, S., Fonseca-Pedrero, E., MacBeth, A., Popolo, R. & Dimaggio, G. (2020). Metacognitive Interpersonal Therapy in Group (MIT-G) for Personality Disorders: Preliminary Results from a Pilot Study in a Public Mental Health Setting. Journal of Contemporary Psychotherapy, 50(3), 197-203. https://doi.org/10.1007/s10879-020-09453-9 Ogden, P., & Fisher, J. (2015). Sensorimotor psychotherapy: Interventions for trauma and attachment. W. W. Norton and Company, Inc. Popolo, R., MacBeth, A., Canfora, F., Rebecchi, D., Toselli, C., Salvatore, G. & Dimaggio, G. (2019). Metacognitive Interpersonal Therapy in group (MIT-G) for young adults personality disorders. A pilot randomized controlled trial. Psychology and Psychotherapy: Theory, Research & Practice, 92, 342-358. DOI:10.1111/papt.12182 Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.). Guilford. Stiegler, J.R., Molde, H., Schanche, E. (2018). Does an emotion‐focused two‐chair dialogue add to the therapeutic effect of the empathic attunement to affect? Clin Psychol Psychother. 2018; 25: e86– e95. https:// n doi.org/10.1002/cpp.2144 Tripp, J. C., Haller, M., Trim, R. S., Straus, E., Bryan, C. J., Davis, B. C., Lyons, R., Hamblen, J. L., & Norman, S. B. (2020). Does exposure exacerbate symptoms in veterans with PTSD and alcohol use disorder? Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. https://doi.org/10.1037/tra0000634
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and procedures (2nd ed.). Guilford. Stiegler, J.R., Molde, H., Schanche, E. (2018). Does an emotion‐focused two‐chair dialogue add to the therapeutic effect of the empathic attunement to affect? Clin Psychol Psychother. 2018; 25: e86– e95. https://doi.org/10.1002/cpp.2144 Tripp, J. C., Haller, M., Trim, R. S., Straus, E., Bryan, C. J., Davis, B. C., Lyons, R., Hamblen, J. L., & Norman, S. B. (2020). Does exposure exacerbate symptoms in veterans with PTSD and alcohol use disorder? Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. https://doi.org/10.1037/tra0000634 The Integrative Therapist Volume 6, Issue 4 • Dec 2020
Final words from current Editor and introducing our new SEPI Newsletter Editor!
Dear SEPI friends Alexandre Vaz Stating the obvious: this year did not turn out the way we all expected. So many of our plans got scrapped, so many deadlines missed or postponed (coff coff), and so many opportunities to test our n own flexibility. Throughout all this, SEPI persists in getting with the times, having promoted more online content this year than ever before, and taking steps to remain as inclusive as possible (e.g. deciding to go for a mixed format of both online and in person international conference next year). All good things must come to other new exciting things. In this spirit, I'm very happy to say I've had "I could not immense pleasure in the luxury of acting as Editor for this newsletter. I want to formally thank everyone that's helped along the way (unfortunately I'm sure to miss so many, so please consider yourselves be happier to included even if you are not here!): thanks so much Catherine, Sasha, Shigeru, Tracy, Jefferey, Tracey, Marv, Paul, Nuno, Tom, Ioana, and many, many others. announce I now want to give someone else the same great opportunity I once had: To have an enthusiasistic young career psychologist the chance to prepare this newsletter and continue promoting our integrative Alan Kian, efforts around the world. I could not be happier to announce Alan Kian, from York University, Toronto, as our next SEPI Newsletter Editor. Alan is a kind, smart and enthusiastic guy (my personal fav from York combination of qualities). He will make a great Editor! I asked Alan to write a few words about himself, University, as a first presentation for our SEPI community. Here they are: "I am a 2nd year MA student studying at York Toronto, University in Toronto, Canada, under the supervision of Dr. Alberta Pos. I have found that my as our next early career interests in terms of psychotherapy revolve around approaches put forth by Irvin Yalom SEPI - an ever-expanding approach revolving around person-centered and existential philosophies. Of Newsletter course, being a student at York University, I am also particularly fond of EFT and process-based Editor." therapy. I have recently started to see clients, and am excited to see how this will develop! Alan Kian
Prior to the onset of the events surrounding COVID, I, along with Dr. Pos, developed a brief online format of a psychoeducational emotional intelligence workshop that she had previously developed and found effective in person. This is the focus of my MA research. Looking forward to my PhD studies, I am looking into developing this further, with added focus on potential side effects of the online format in post-COVID daily life. n I always have on-going personal projects, mostly based around (these days anyway) being a bit more nerdy and finishing up so called "bucket list books". I am currently tackling the beast that is Moby- Dick, so fingers crossed!" Thanks Alan and thanks again to all who continue to make the SEPI dream a reality!
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and procedures (2nd ed.). Guilford. Stiegler, J.R., Molde, H., Schanche, E. (2018). Does an emotion‐focused two‐chair dialogue add to the therapeutic effect of the empathic attunement to affect? Clin Psychol Psychother. 2018; 25: e86– e95. https://doi.org/10.1002/cpp.2144 Tripp, J. C., Haller, M., Trim, R. S., Straus, E., Bryan, C. J., Davis, B. C., Lyons, R., Hamblen, J. L., & Norman, S. B. (2020). Does exposure exacerbate symptoms in veterans with PTSD and alcohol use disorder? Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. https://doi.org/10.1037/tra0000634