Sandra J. Llera

A Review of Technology-Assisted Self-Help and Minimal Contact Therapies for Anxiety and Depression: Is Human Contact Necessary for Therapeutic Efficacy?

Technology-based self-help and minimal contact therapies have been proposed as effective and low-cost interventions for anxiety and mood disorders. The present article reviews the literature published before 2010 on these treatments for anxiety and depression using self-help and decreased therapist-contact interventions. Treatment studies are examined by disorder as well as amount of therapist contact, ranging from self-administered therapy and predominantly self-help interventions to minimal contact therapy where the therapist is actively involved in treatment but to a lesser degree than traditional therapy and predominantly therapist-administered treatments involving regular contact with a therapist for a typical number of sessions. In the treatment of anxiety disorders, it is concluded that self-administered and predominantly self-help interventions are most effective for motivated clients. Conversely, minimal-contact therapies have demonstrated efficacy for the greatest variety of anxiety diagnoses when accounting for both attrition and compliance. Additionally, predominantly self-help computer-based cognitive and behavioral interventions are efficacious in the treatment of subthreshold mood disorders. However, therapist-assisted treatments remain optimal in the treatment of clinical levels of depression. Although the most efficacious amount of therapist contact varies by disorder, computerized treatments have been shown to be a less-intensive, cost-effective way to deliver empirically validated treatments for a variety of psychological problems.

A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry

An important emphasis of the literature on generalized anxiety disorder (GAD) has been to achieve a greater understanding of the function of emotion (e.g., avoidance, dysregulation) in the etiology and maintenance of this disorder. The purpose of the following paper is to propose a new way of conceptualizing emotional sequelae in GAD by detailing the Contrast Avoidance Model of Worry. In presenting this model, we review theory and data that led to our current position, which is that individuals with GAD are more sensitive to feeling emotionally vulnerable to unexpected negative events, and that worry (the key pathological feature of GAD) is employed to prolong and maintain a negative emotional state thereby avoiding an unexpected negative emotional shift, or contrast experience. We also discuss implications for treatment given the presence of a new target for emotional exposure techniques. Finally, we establish the Contrast Avoidance Model within the framework of extant theories and models of pathogenic processes of GAD.

A Review of Technology-Assisted Self-Help and Minimal Contact Therapies for Drug and Alcohol Abuse and Smoking Addiction: Is Human Contact Necessary for Therapeutic Efficacy?

Technology-based self-help and minimal contact therapies have been proposed as effective and low-cost interventions for addictive disorders, such as nicotine, alcohol, and drug abuse and addiction. The present article reviews the literature published before 2010 on computerized treatments for drug and alcohol abuse and dependence and smoking addiction. Treatment studies are examined by disorder as well as amount of therapist contact, ranging from self-administered therapy and predominantly self-help interventions to minimal contact therapy where the therapist is actively involved in treatment but to a lesser degree than traditional therapy and predominantly therapist-administered treatments involving regular contact with a therapist for a typical number of sessions. In the treatment of substance use and abuse it is concluded that self-administered and predominantly self-help computer-based cognitive and behavioral interventions are efficacious, but some therapist contact is important for greater and more sustained reductions in addictive behavior.

Worry and Generalized Anxiety Disorder: A Review and Theoretical Synthesis of Evidence on Nature, Etiology, Mechanisms, and Treatment

Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidance model may help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.

Effects of Worry on Physiological and Subjective Reactivity to Emotional Stimuli in Generalized Anxiety Disorder and Nonanxious Control Participants

The present study examined the effect of worry versus relaxation and neutral thought activity on both physiological and subjective responding to positive and negative emotional stimuli. Thirty-eight participants with generalized anxiety disorder (GAD) and 35 nonanxious control participants were randomly assigned to engage in worry, relaxation, or neutral inductions prior to sequential exposure to each of four emotion-inducing film clips. The clips were designed to elicit fear, sadness, happiness, and calm emotions. Self reported negative and positive affect was assessed following each induction and exposure, and vagal activity was measured throughout. Results indicate that worry (vs. relaxation) led to reduced vagal tone for the GAD group, as well as higher negative affect levels for both groups. Additionally, prior worry resulted in less physiological and subjective responding to the fearful film clip, and reduced negative affect in response to the sad clip. This suggests that worry may facilitate avoidance of processing negative emotions by way of preventing a negative emotional contrast. Implications for the role of worry in emotion avoidance are discussed.

Emotional instability, poor emotional awareness, and the development of borderline personality.

Emotional instability and poor emotional awareness are cardinal features of the emotional dysregulation associated with borderline personality disorder (BPD). Most models of the development of BPD include child negative emotional reactivity and grossly inadequate caregiving (e.g., abuse, emotional invalidation) as major contributing factors. However, early childhood emotional reactivity and exposure to adverse family situations are associated with a diverse range of long-term outcomes. We examine the known effects of these risk factors on early childhood emotional functioning and their potential links to the emergence of chronic emotional instability and poor emotional awareness. This examination leads us to advocate new research directions. First, we advocate for enriching the developmental assessment of childrens emotional functioning to more closely capture clinically relevant aspects. Second, we advocate for conceptualizing childrens early family experiences in terms of the proximal emotional environment to which young children may be or become sensitive. Such approaches should contribute to our ability to identify risk for BPD and guide preventive intervention.

Development and validation of two measures of emotional contrast avoidance: The contrast avoidance questionnaires

The Contrast Avoidance (CA) model (Newman & Llera, 2011) proposed that individuals with generalized anxiety disorder (GAD) fear sharp emotional shifts (or contrasts), such as the shift from a pleasant or neutral state to one of sudden distress following a negative event. Further, the model suggests that chronic worry is employed by those with GAD to sustain negative emotionality as a means to avoid sudden shifts into negativity. The model has received empirical support; however, no validated measure exists to assess CA tendencies. In this paper we developed and tested two measures of CA: one focusing on worry, and another examining broader mechanisms of CA that could be used test whether CA is applicable to other disorders. In Study 1, Part 1, we used 3 samples of participants (each N=410) to perform item reduction, exploratory factor analysis, and confirmatory factor analysis. In Study 1, Part 2, we performed tests of construct validity. In Study 2, we used a new sample (N=126) to determine test-retest reliability. All data point to the strong psychometric properties of the CA questionnaires and their relationship to GAD. Both measures distinguished between participants reporting clinical levels of GAD symptoms and nonanxious controls, demonstrating their utility as complementary measures of CA tendencies.