Page 1
Cognitive therapy for challenging problems
Arnoud Arntz
overview
bull An historical viewbull What has been achievedbull Remaining challengesbull Possible solutions
History
bull 2nd half of previous century ldquocognitive revolutionrdquo in psychologyndash Organism forms mental representations ndash These guide information processing
bull Even for the most simple learning process habituation mental representation is needed to explain phenomena such as dishabituationndash In very simple organisms
Habituation reduced response to stimulus with repetition
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentation
Dishabituation increased response to stimulus after habituation
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentationomitted presentation 8
Omitted stimulus
Dishabituation orienting response
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentationomitted presentation 8
Omitted stimulus
Interpretation
bull Organism builds a representation of the stimulus including context timing etc
bull This representation when correct inhibits the response to the stimulus
bull When expectation is violatedndash Orienting responsendash Habituation process is interrupted
Development of Cognitive Therapy
bull Cognitive revolutionbull Verbal reasoning and schemarsquos (often reduced
to ldquobeliefsrdquo) became centralbull Debate between old-school behaviorists and
new CT adherentsndash Ignoring the cognitive revolution in basic
conditioning research
Early successes of Cognitive Therapy
bull Increased understanding of disordersndash By clarifying the core beliefs ideas
bull Improved treatment of depression panic disorder social phobiandash Eg panic disorder without agoraphobia plusmn 80
panic freendash Less relapse than with pharmacotherapyndash But behaviour therapy (exposure in vivo) needed
for agoraphobia
Problems with Cognitive Therapybull Tendency to equate cognition with verbal conscious
thoughtsbull Tendency to use verbal logical reasoning to change
mental representationsbull Focus on reasoning errors and (other) biases instead of
underlying mental representationndash Causal status of biases is weak
bull Some disorders difficult to treat with lsquopurersquo CTndash Eg Phobiasndash Addictionndash Personality Disorders
bull Relapsehellip
Relapse after successful C(B)T for depression
bull After successful C(B)T gt 50 relapses within 2 years (Vittengl et al 2007)ndash Recent RCTs no better results
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 2
overview
bull An historical viewbull What has been achievedbull Remaining challengesbull Possible solutions
History
bull 2nd half of previous century ldquocognitive revolutionrdquo in psychologyndash Organism forms mental representations ndash These guide information processing
bull Even for the most simple learning process habituation mental representation is needed to explain phenomena such as dishabituationndash In very simple organisms
Habituation reduced response to stimulus with repetition
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentation
Dishabituation increased response to stimulus after habituation
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentationomitted presentation 8
Omitted stimulus
Dishabituation orienting response
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentationomitted presentation 8
Omitted stimulus
Interpretation
bull Organism builds a representation of the stimulus including context timing etc
bull This representation when correct inhibits the response to the stimulus
bull When expectation is violatedndash Orienting responsendash Habituation process is interrupted
Development of Cognitive Therapy
bull Cognitive revolutionbull Verbal reasoning and schemarsquos (often reduced
to ldquobeliefsrdquo) became centralbull Debate between old-school behaviorists and
new CT adherentsndash Ignoring the cognitive revolution in basic
conditioning research
Early successes of Cognitive Therapy
bull Increased understanding of disordersndash By clarifying the core beliefs ideas
bull Improved treatment of depression panic disorder social phobiandash Eg panic disorder without agoraphobia plusmn 80
panic freendash Less relapse than with pharmacotherapyndash But behaviour therapy (exposure in vivo) needed
for agoraphobia
Problems with Cognitive Therapybull Tendency to equate cognition with verbal conscious
thoughtsbull Tendency to use verbal logical reasoning to change
mental representationsbull Focus on reasoning errors and (other) biases instead of
underlying mental representationndash Causal status of biases is weak
bull Some disorders difficult to treat with lsquopurersquo CTndash Eg Phobiasndash Addictionndash Personality Disorders
bull Relapsehellip
Relapse after successful C(B)T for depression
bull After successful C(B)T gt 50 relapses within 2 years (Vittengl et al 2007)ndash Recent RCTs no better results
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 3
History
bull 2nd half of previous century ldquocognitive revolutionrdquo in psychologyndash Organism forms mental representations ndash These guide information processing
bull Even for the most simple learning process habituation mental representation is needed to explain phenomena such as dishabituationndash In very simple organisms
Habituation reduced response to stimulus with repetition
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentation
Dishabituation increased response to stimulus after habituation
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentationomitted presentation 8
Omitted stimulus
Dishabituation orienting response
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentationomitted presentation 8
Omitted stimulus
Interpretation
bull Organism builds a representation of the stimulus including context timing etc
bull This representation when correct inhibits the response to the stimulus
bull When expectation is violatedndash Orienting responsendash Habituation process is interrupted
Development of Cognitive Therapy
bull Cognitive revolutionbull Verbal reasoning and schemarsquos (often reduced
to ldquobeliefsrdquo) became centralbull Debate between old-school behaviorists and
new CT adherentsndash Ignoring the cognitive revolution in basic
conditioning research
Early successes of Cognitive Therapy
bull Increased understanding of disordersndash By clarifying the core beliefs ideas
bull Improved treatment of depression panic disorder social phobiandash Eg panic disorder without agoraphobia plusmn 80
panic freendash Less relapse than with pharmacotherapyndash But behaviour therapy (exposure in vivo) needed
for agoraphobia
Problems with Cognitive Therapybull Tendency to equate cognition with verbal conscious
thoughtsbull Tendency to use verbal logical reasoning to change
mental representationsbull Focus on reasoning errors and (other) biases instead of
underlying mental representationndash Causal status of biases is weak
bull Some disorders difficult to treat with lsquopurersquo CTndash Eg Phobiasndash Addictionndash Personality Disorders
bull Relapsehellip
Relapse after successful C(B)T for depression
bull After successful C(B)T gt 50 relapses within 2 years (Vittengl et al 2007)ndash Recent RCTs no better results
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 4
Habituation reduced response to stimulus with repetition
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentation
Dishabituation increased response to stimulus after habituation
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentationomitted presentation 8
Omitted stimulus
Dishabituation orienting response
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentationomitted presentation 8
Omitted stimulus
Interpretation
bull Organism builds a representation of the stimulus including context timing etc
bull This representation when correct inhibits the response to the stimulus
bull When expectation is violatedndash Orienting responsendash Habituation process is interrupted
Development of Cognitive Therapy
bull Cognitive revolutionbull Verbal reasoning and schemarsquos (often reduced
to ldquobeliefsrdquo) became centralbull Debate between old-school behaviorists and
new CT adherentsndash Ignoring the cognitive revolution in basic
conditioning research
Early successes of Cognitive Therapy
bull Increased understanding of disordersndash By clarifying the core beliefs ideas
bull Improved treatment of depression panic disorder social phobiandash Eg panic disorder without agoraphobia plusmn 80
panic freendash Less relapse than with pharmacotherapyndash But behaviour therapy (exposure in vivo) needed
for agoraphobia
Problems with Cognitive Therapybull Tendency to equate cognition with verbal conscious
thoughtsbull Tendency to use verbal logical reasoning to change
mental representationsbull Focus on reasoning errors and (other) biases instead of
underlying mental representationndash Causal status of biases is weak
bull Some disorders difficult to treat with lsquopurersquo CTndash Eg Phobiasndash Addictionndash Personality Disorders
bull Relapsehellip
Relapse after successful C(B)T for depression
bull After successful C(B)T gt 50 relapses within 2 years (Vittengl et al 2007)ndash Recent RCTs no better results
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 5
Dishabituation increased response to stimulus after habituation
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentationomitted presentation 8
Omitted stimulus
Dishabituation orienting response
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentationomitted presentation 8
Omitted stimulus
Interpretation
bull Organism builds a representation of the stimulus including context timing etc
bull This representation when correct inhibits the response to the stimulus
bull When expectation is violatedndash Orienting responsendash Habituation process is interrupted
Development of Cognitive Therapy
bull Cognitive revolutionbull Verbal reasoning and schemarsquos (often reduced
to ldquobeliefsrdquo) became centralbull Debate between old-school behaviorists and
new CT adherentsndash Ignoring the cognitive revolution in basic
conditioning research
Early successes of Cognitive Therapy
bull Increased understanding of disordersndash By clarifying the core beliefs ideas
bull Improved treatment of depression panic disorder social phobiandash Eg panic disorder without agoraphobia plusmn 80
panic freendash Less relapse than with pharmacotherapyndash But behaviour therapy (exposure in vivo) needed
for agoraphobia
Problems with Cognitive Therapybull Tendency to equate cognition with verbal conscious
thoughtsbull Tendency to use verbal logical reasoning to change
mental representationsbull Focus on reasoning errors and (other) biases instead of
underlying mental representationndash Causal status of biases is weak
bull Some disorders difficult to treat with lsquopurersquo CTndash Eg Phobiasndash Addictionndash Personality Disorders
bull Relapsehellip
Relapse after successful C(B)T for depression
bull After successful C(B)T gt 50 relapses within 2 years (Vittengl et al 2007)ndash Recent RCTs no better results
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 6
Dishabituation orienting response
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 1011121314151617181920
regular presentationomitted presentation 8
Omitted stimulus
Interpretation
bull Organism builds a representation of the stimulus including context timing etc
bull This representation when correct inhibits the response to the stimulus
bull When expectation is violatedndash Orienting responsendash Habituation process is interrupted
Development of Cognitive Therapy
bull Cognitive revolutionbull Verbal reasoning and schemarsquos (often reduced
to ldquobeliefsrdquo) became centralbull Debate between old-school behaviorists and
new CT adherentsndash Ignoring the cognitive revolution in basic
conditioning research
Early successes of Cognitive Therapy
bull Increased understanding of disordersndash By clarifying the core beliefs ideas
bull Improved treatment of depression panic disorder social phobiandash Eg panic disorder without agoraphobia plusmn 80
panic freendash Less relapse than with pharmacotherapyndash But behaviour therapy (exposure in vivo) needed
for agoraphobia
Problems with Cognitive Therapybull Tendency to equate cognition with verbal conscious
thoughtsbull Tendency to use verbal logical reasoning to change
mental representationsbull Focus on reasoning errors and (other) biases instead of
underlying mental representationndash Causal status of biases is weak
bull Some disorders difficult to treat with lsquopurersquo CTndash Eg Phobiasndash Addictionndash Personality Disorders
bull Relapsehellip
Relapse after successful C(B)T for depression
bull After successful C(B)T gt 50 relapses within 2 years (Vittengl et al 2007)ndash Recent RCTs no better results
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 7
Interpretation
bull Organism builds a representation of the stimulus including context timing etc
bull This representation when correct inhibits the response to the stimulus
bull When expectation is violatedndash Orienting responsendash Habituation process is interrupted
Development of Cognitive Therapy
bull Cognitive revolutionbull Verbal reasoning and schemarsquos (often reduced
to ldquobeliefsrdquo) became centralbull Debate between old-school behaviorists and
new CT adherentsndash Ignoring the cognitive revolution in basic
conditioning research
Early successes of Cognitive Therapy
bull Increased understanding of disordersndash By clarifying the core beliefs ideas
bull Improved treatment of depression panic disorder social phobiandash Eg panic disorder without agoraphobia plusmn 80
panic freendash Less relapse than with pharmacotherapyndash But behaviour therapy (exposure in vivo) needed
for agoraphobia
Problems with Cognitive Therapybull Tendency to equate cognition with verbal conscious
thoughtsbull Tendency to use verbal logical reasoning to change
mental representationsbull Focus on reasoning errors and (other) biases instead of
underlying mental representationndash Causal status of biases is weak
bull Some disorders difficult to treat with lsquopurersquo CTndash Eg Phobiasndash Addictionndash Personality Disorders
bull Relapsehellip
Relapse after successful C(B)T for depression
bull After successful C(B)T gt 50 relapses within 2 years (Vittengl et al 2007)ndash Recent RCTs no better results
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 8
Development of Cognitive Therapy
bull Cognitive revolutionbull Verbal reasoning and schemarsquos (often reduced
to ldquobeliefsrdquo) became centralbull Debate between old-school behaviorists and
new CT adherentsndash Ignoring the cognitive revolution in basic
conditioning research
Early successes of Cognitive Therapy
bull Increased understanding of disordersndash By clarifying the core beliefs ideas
bull Improved treatment of depression panic disorder social phobiandash Eg panic disorder without agoraphobia plusmn 80
panic freendash Less relapse than with pharmacotherapyndash But behaviour therapy (exposure in vivo) needed
for agoraphobia
Problems with Cognitive Therapybull Tendency to equate cognition with verbal conscious
thoughtsbull Tendency to use verbal logical reasoning to change
mental representationsbull Focus on reasoning errors and (other) biases instead of
underlying mental representationndash Causal status of biases is weak
bull Some disorders difficult to treat with lsquopurersquo CTndash Eg Phobiasndash Addictionndash Personality Disorders
bull Relapsehellip
Relapse after successful C(B)T for depression
bull After successful C(B)T gt 50 relapses within 2 years (Vittengl et al 2007)ndash Recent RCTs no better results
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 9
Early successes of Cognitive Therapy
bull Increased understanding of disordersndash By clarifying the core beliefs ideas
bull Improved treatment of depression panic disorder social phobiandash Eg panic disorder without agoraphobia plusmn 80
panic freendash Less relapse than with pharmacotherapyndash But behaviour therapy (exposure in vivo) needed
for agoraphobia
Problems with Cognitive Therapybull Tendency to equate cognition with verbal conscious
thoughtsbull Tendency to use verbal logical reasoning to change
mental representationsbull Focus on reasoning errors and (other) biases instead of
underlying mental representationndash Causal status of biases is weak
bull Some disorders difficult to treat with lsquopurersquo CTndash Eg Phobiasndash Addictionndash Personality Disorders
bull Relapsehellip
Relapse after successful C(B)T for depression
bull After successful C(B)T gt 50 relapses within 2 years (Vittengl et al 2007)ndash Recent RCTs no better results
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 10
Problems with Cognitive Therapybull Tendency to equate cognition with verbal conscious
thoughtsbull Tendency to use verbal logical reasoning to change
mental representationsbull Focus on reasoning errors and (other) biases instead of
underlying mental representationndash Causal status of biases is weak
bull Some disorders difficult to treat with lsquopurersquo CTndash Eg Phobiasndash Addictionndash Personality Disorders
bull Relapsehellip
Relapse after successful C(B)T for depression
bull After successful C(B)T gt 50 relapses within 2 years (Vittengl et al 2007)ndash Recent RCTs no better results
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 11
Relapse after successful C(B)T for depression
bull After successful C(B)T gt 50 relapses within 2 years (Vittengl et al 2007)ndash Recent RCTs no better results
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 12
Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 13
Relapse after successful C(B)T for depression
bull CT superior to pharmacotherapy in relapsebull CT equivalent to other psychotherapybull Relapse prevention program limited effects
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 14
Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015)
75
54 54
42
0102030405060708090
100
Pharma CT Other PsychTher Relapse Prevention
Relapse
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 15
Relapse after successful C(B)T for depression
bull Does CT protect against relapsebull Or does pharmacotherapy increase relapse
ndash Eg by sensitizing the brain for stress by ldquotrainingrdquo neurotransmission in the wrong direction (Hollon et al 2019 Arntz 2019)
bull Current understanding of relapse prevention by CT compensatory skillsndash Not a change at the schema level
bull NOTE 57 remission (Johnsen amp Friborg 2015) 46 no relapse in 2 yr hence only 26 ldquostablyrdquo recovered with CTndash 74 not helped
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 16
Overlooked factors in CT for depression
bull Childhood maltreatment (Nanni et al 2012 Buckman et al 2018)
bull Underlying schemasbull Experiential techniques
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 17
Imagery Rescripting vs CT for depression (Yuen Ting submitted)
Timeηp
2 = 71Time x Conditionηp
2 = 16 (large ES)
CTPre-Post d = 101Pre-FU d = 109
ImRsPre-Post d = 170Pre-FU d = 197
Differential drsquosPre-Post d = 069Pre-FU d = 088
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 18
Low relapse after recovery PTSD Personality Disorders
bull PTSD treatment (if trauma-focused)ndash 9 at 1 year (vs 30 in depression) in childhood
abuse related PTSD (Boterhoven- de Haan et al in prep Raabe et al in prep)
bull Schema Therapy for BPDndash Zero relapse at 1 yr FU (Dickhaut amp Arntz 2012
Wetzelaer et al 2014)ndash Further improvement after treatment
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 19
Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014
No treatment
BPDSI
No treatment
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 20
What is the difference
1 Focus on representations ndash Early memories of trauma (abuse neglect etc)ndash Schemas
2 Use of experiential techniquesndash Activation of the representation on perceptual
and emotional levelndash Hence stronger effects of re-interpretation (new
meanings) bull Eg Emily Holmesrsquo work on imagery
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 21
Prediction
bull Better effects when treatment focuses on mental representations amp includes experiential techniques than when focus is on skills andor biases
bull Well documented for PTSDndash Trauma-focused CBT EMDR is superior to non-
trauma-focused CBT
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 22
Childhood-abuse PTSD treatments for adults effect size g meta-analysis
Ehring et al Clinical Psychology Review 34 (2014) 645ndash657
002040608
112141618
2
post FU
effect size g
Tr-f CBTnon-Tr-f CBT
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 23
ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizes
Raabe et al in preparation
255 260
0
05
1
15
2
25
3
ImRs STAIR+ImRs
Change (Long Term CAPS)
159
042067
0
05
1
15
2
25
3
ImRs WL STAIR
Change (short term CAPS)Cohenrsquos d Cohenrsquos d
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 24
Emotion Regulation (DERS pre-post)
Raabe et al in prep
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 25
Chart1 STAIR
ImRs
WL
10973
1107238
1021937
1001579
884706
974211
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
pre pre pre post post post
Page 26
Sheet1 Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
STAIR versus ImRs versus WL Descriptives CAPS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound CAPS M1capsSum STAIR 16 751875 1531108 382777 670288 833462 4300 10100 pre post change d SD_M1 IR 16 797500 1634829 408707 710386 884614 6000 11300 STAIR 751875 62875 123125 07206904095 170843122627 WL 19 715263 1897474 435310 623808 806718 3700 10500 ImRs 7975 4475 35 20486630929 170843122627 Total 51 752549 1708431 239228 704499 800599 3700 11300 WL 715263157895 643157894737 72105263158 04220554041 170843122627 M2capsSum STAIR 16 628750 2826983 706746 478111 779389 000 9600 IR 16 447500 3288870 822218 272248 622752 000 9700 WL 19 643158 2472527 567237 523986 762330 2400 11700 Total 51 577255 2938032 411407 494621 659888 000 11700 PDS pre post change d SD_M1 PDS STAIR 4055 327368 78132 08043195166 971405 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 41 213529 196471 20225446647 971405 Lower Bound Upper Bound WL 364 311579 52421 05396410354 971405 M1pdsSum STAIR 20 4055 906395 202676 363079 447921 27 55 IR 21 41 964365 210442 366103 453897 27 59 WL 20 364 1021042 228312 316214 411786 18 53 Total 61 393443 971405 124376 368564 418321 18 59 m2pdsSum STAIR 19 327368 1571214 360461 251638 403099 0 57 IR 17 213529 1714257 415768 12539 301668 0 50 WL 19 311579 1108183 254235 258166 364992 11 53 Total 55 286727 1533461 206772 245272 328183 0 57 DERS DERS N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post change d SD_M1 Lower Bound Upper Bound STAIR 10973 1001579 95721 0418253343 2288589 DERS total score STAIR 20 10973 2480418 554638 981213 1213387 6789 146 ImRs 1107238 884706 222532 09723545818 2288589 IR 21 1107238 2252825 491607 1004691 1209785 82 1512 WL 1021937 974211 47726 02085389731 2288589 WL 20 1021937 214052 478635 921758 1122116 67 137 Total 61 1076012 2288589 293024 1017399 1134626 67 1512 DERS total score STAIR 19 1001579 268085 615029 872366 1130792 62 149 IR 17 884706 2999191 727411 730502 103891 47 139 WL 19 974211 2349543 539022 860966 1087455 59 143 Total 55 956 2673159 360449 883734 1028266 47 149 BDI BDI pre post change d SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIR 344 246842 97158 07238863573 1342172 Lower Bound Upper Bound ImRs 346667 189412 157255 11716456609 1342172 M1bdiSum STAIR 20 344 1211089 270808 287319 400681 10 55 WL 3105 258421 52079 03880203133 1342172 IR 21 346667 1591645 347325 274216 419117 10 66 WL 20 3105 1211991 271009 253777 367223 7 53 Total 61 333934 1342172 171848 29956 368309 7 66 M2bdiSum STAIR 19 246842 1485879 340884 175225 318459 0 55 IR 17 189412 1663006 403338 103908 274916 0 47 WL 19 258421 1275087 292525 196964 319878 6 58 Total 55 233091 1478722 199391 193115 273066 0 58 BAI pre post change d SD_M1 STAIR 299 230526 68474 04362676732 1569541 BAI ImRs 297619 171176 126443 08056049507 1569541 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 2605 247895 12605 00803101034 1569541 Lower Bound Upper Bound M1baiSum STAIR 20 299 1507839 337163 228431 369569 3 54 IR 21 297619 1579843 34475 225705 369533 9 54 WL 20 2605 1666536 372649 182504 338496 6 57 Total 61 285902 1569541 200959 245704 326099 3 57 M2baiSum STAIR 19 230526 1446634 33188 160801 300252 2 52 IR 17 171176 1672529 405648 85183 25717 0 51 WL 19 247895 1714182 39326 165274 330516 1 63 Total 55 218182 1616133 217919 174492 261872 0 63 DIS-Q pre post change d SD_M1 STAIR 22365 19566 02799 03756744423 074506 DIS-Q ImRs 22576 15907 06669 0895095697 074506 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum WL 20432 1944 00992 01331436394 074506 Lower Bound Upper Bound M1DisqSum STAIR 20 22365 067412 015074 1921 2552 132 371 IR 21 22576 080768 017625 189 26253 138 405 WL 20 20432 076297 01706 16861 24002 108 369 Total 61 21804 074506 009539 19896 23712 108 405 M2DisqSum STAIR 19 19566 063235 014507 16518 22613 113 306 IR 17 15907 043382 010522 13676 18137 102 254 WL 19 1944 079876 018325 1559 2329 111 378 Total 55 18391 065565 008841 16619 20164 102 378 STAIRImRs versus ImRs CAPS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 CAPS STAIRImRs 70 359286 26 340714 44 17835385165 23032717976 1910326 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 751935 4496 3612 302335 390735 15826356339 20453838769 1910326 Lower Bound Upper Bound capspresum STAIRIR 30 70 1948474 355741 627243 772757 24 109 IR 31 751935 1868586 335608 683395 820476 24 117 Total 61 726393 1910326 244592 677468 775319 24 117 capspostsum STAIRIR 28 359286 2865236 541479 248183 470388 0 104 IR 25 4496 3064104 612821 32312 57608 0 97 Total 53 401887 2967002 407549 320106 483667 0 104 capsfusum STAIRIR 26 26 2331866 457317 165814 354186 0 78 IR 25 3612 2887808 577562 241997 480403 0 91 Total 51 309608 2642496 370023 235286 383929 0 91 PDS PDS pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum STAIRImRs 365333 163929 126538 201404 238795 18711201042 2218496779 1076382 Lower Bound Upper Bound ImRs 389333 228 1612 161333 228133 14988452055 21194427257 1076382 pdspresum STAIRIR 30 365333 112579 20554 323296 407371 16 55 IR 30 389333 1029541 187968 35089 427777 11 59 Total 60 377333 1076382 13896 349527 405139 11 59 pdspostsum STAIRIR 28 163929 1470283 277857 106917 22094 0 51 IR 25 228 1584035 316807 162614 293386 0 50 Total 53 194151 1544274 212122 151585 236716 0 51 pdsfusum STAIRIR 26 126538 1275286 250104 75029 178048 0 52 IR 25 1612 1496195 299239 9944 22296 0 49 Total 51 143529 1385038 193944 104575 182484 0 52 DIS_Q pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 DIS-Q STAIRImRs 2073 15862 14728 04868 06002 06378573862 07864461857 076318 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum ImRs 22295 16411 15497 05884 06798 07709845646 08907466129 076318 Lower Bound Upper Bound disqpresum STAIRIR 30 2073 073313 013385 17993 23468 111 378 IR 30 22295 079676 014547 1932 2527 114 405 Total 60 21513 076318 009853 19541 23484 111 405 disqpostsum STAIRIR 28 15862 061614 011644 13473 18251 1 381 IR 25 16411 051916 010383 14268 18554 102 303 Total 53 16121 056769 007798 14556 17685 1 381 disqfusum STAIRIR 26 14728 058383 01145 1237 17087 1 392 IR 25 15497 050352 01007 13418 17575 1 286 Total 51 15105 054187 007588 13581 16629 1 392 BDI pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 STAIRImRs 308 144286 135769 163714 172231 11594919352 1219812939 1411946 BDI ImRs 327667 1816 1372 146067 190467 10345084019 134896802 1411946 N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum Lower Bound Upper Bound bdipresum STAIRIR 30 308 136695 24957 256957 359043 10 58 IR 30 327667 1472198 268785 272694 382639 6 66 Total 60 317833 1411946 182281 281359 354308 6 66 bdipostsum STAIRIR 28 144286 1502696 283983 86017 202554 0 57 IR 25 1816 1529074 305815 118483 244717 0 47 Total 53 161887 1512265 207726 120204 20357 0 57 bdifusum STAIRIR 26 135769 1435318 281489 77795 193743 0 53 IR 25 1372 1600396 320079 71139 203261 0 59 Total 51 136471 1503173 210486 94193 178748 0 59 BAI BAI N Mean Std Deviation Std Error 95 Confidence Interval for Mean Minimum Maximum pre post fu change_pre_post change_pre_fu d_post d_fu SD_M1 Lower Bound Upper Bound STAIRImRs 281667 123929 12 157738 161667 09915664862 10162648133 1590796 baipresum STAIRIR 30 281667 1575695 287681 222829 340504 3 56 ImRs 283 1636 1384 1194 1446 07505676404 09089789011 1590796 IR 30 283 1632673 298084 222035 343965 1 63 Total 60 282333 1590796 205371 241239 323428 1 63 baipostsum STAIRIR 28 123929 1286494 243124 74044 173814 0 41 IR 25 1636 1632963 326593 96195 231005 0 51 Total 53 142642 1459472 200474 102413 18287 0 51 baifusum STAIRIR 26 12 1358823 266487 65116 174884 0 50 IR 25 1384 147498 294996 77516 199284 0 51 Total 51 12902 1405739 196843 89483 168557 0 51 4 conditions CAPS CAPS cond M1capsSum M2capsSum M3capsSum M4capsSum FU1capsSum STAIRImRs Mean 757 641053 4011 234375 N 2000 1900 1800 1600 Std Deviation 1459 2649 3081 2245 ImRs Mean 7824 4559 3356 N 2100 1700 1600 Std Deviation 1460 3203 3035 WLSTAIRImRs Mean 6430 5860 4840 2840 3010 N 1000 1000 1000 1000 1000 Std Deviation 1712 2361 2716 2390 2530 WLImRs Mean 7690 6880 4363 4067 N 1000 1000 800 900 Std Deviation 1936 2497 2951 2718 Total Mean 7490 5834 4319 3291 3096 N 6100 5600 3600 1100 5100 Std Deviation 1619 2834 2894 2716 2642 PDS Report cond M1pdsSum m2pdsSum m3pdsSum m4pdsSum fu1pdsSum STAIRImRs Mean 4055 3274 1711 1056 N 2000 1900 1800 1600 Std Deviation 906 1571 1497 1025 ImRs Mean 4100 2135 1600 N 2100 1700 1600 Std Deviation 964 1714 1630 WLSTAIRImRs Mean 3400 2850 2730 1510 1600 N 1000 1000 1000 1000 1000 Std Deviation 926 1129 1461 1491 1601 WLImRs Mean 3880 3411 2588 1633 N 1000 900 800 900 Std Deviation 1102 1069 1314 1316 Total Mean 3934 2867 2189 1618 1435 N 6100 5500 3600 1100 5100 Std Deviation 971 1533 1490 1459 1385 DIS-Q cond M1DisqSum M2DisqSum M3DisqSum M4DisqSum FU1DisqSum STAIRImRs Mean 224 196 157 141 N 2000 1900 1800 1600 Std Deviation 067 063 050 033 ImRs Mean 226 159 150 N 2100 1700 1600 Std Deviation 081 043 046 WLSTAIRImRs Mean 197 175 169 162 158 N 1000 1000 1000 1000 1000 Std Deviation 071 077 074 081 086 WLImRs Mean 211 216 175 165 N 1000 900 800 900 Std Deviation 085 081 069 058 Total Mean 218 184 164 166 151 N 6100 5500 3600 1100 5100 Std Deviation 075 066 060 078 054 BDI Report cond M1bdiSum M2bdiSum M3bdiSum M4bdiSum fu1bdiSum STAIRImRs Mean 3440 2468 1406 1200 N 2000 1900 1800 1600 Std Deviation 1211 1486 1434 1325 ImRs Mean 3467 1894 1563 N 2100 1700 1600 Std Deviation 1592 1663 1824 WLSTAIRImRs Mean 2710 2360 1960 1510 1610 N 1000 1000 1000 1000 1000 Std Deviation 1345 1435 1596 1698 1638 WLImRs Mean 3500 2833 1650 1033 N 1000 900 800 900 Std Deviation 972 1099 1284 1116 Total Mean 3339 2331 1614 1582 1365 N 6100 5500 3600 1100 5100 Std Deviation 1342 1479 1428 1628 1503 BAI Report cond M1baiSum M2baiSum M3baiSum M4baiSum Fu1baiSum STAIRImRs Mean 2990 2305 1139 919 N 2000 1900 1800 1600 Std Deviation 1508 1447 1206 974 ImRs Mean 2976 1712 1406 N 2100 1700 1600 Std Deviation 1580 1673 1474 WLSTAIRImRs Mean 2070 2470 2170 1420 1650 N 1000 1000 1000 1000 1000 Std Deviation 1667 1732 1538 1470 1784 WLImRs Mean 3140 2489 1475 1344 N 1000 900 800 900 Std Deviation 1565 1799 1645 1565 Total Mean 2859 2182 1500 1391 1290 N 6100 5500 3600 1100 5100 Std Deviation 1570 1616 1432 1397 1406
Page 27
Sheet1 PDS
STAIR
ImRs
WL
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 28
Sheet2 STAIR
ImRs
WL
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 29
Sheet3 DERS
BDI-II
STAIR
ImRs
WL
BAI
STAIR
ImRs
WL
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 30
DIS-Q
STAIR
ImRs
WL
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 31
STAIR
ImRs
WL
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 32
CAPS
STAIRImRs
ImRs
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 33
PDS
STAIRImRs
ImRs
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 34
DIS Q
STAIRImRs
ImRs
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 35
STAIRImRs
ImRs
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 36
BAI
STAIRImRs
ImRs
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 37
CAPS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 38
BDI-II
PDS
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
DIS-Q
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 39
BDI-II
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 40
BAI
STAIRImRs
ImRs
WLSTAIRImRs
WLImRs
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 41
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 42
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 43
Guilt Shame Anger Cohenrsquos d (pre-post)
0
02
04
06
08
1
12
14
16
18
2
ImRs Waitlist STAIR
Anger
Raabe et al in prep
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 44
Chart1 Guilt
18786066306
0250214046
02836784812
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 45
Sheet1 Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
d Guilt ImRs 18786066306 Waitlist 0250214046 STAIR 02836784812 To resize chart data range drag lower right corner of range
Page 46
Chart1 Shame
16210417104
02892321456
03975815832
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
Page 47
Sheet1 Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
d Shame ImRs 16210417104 Waitlist 02892321456 STAIR 03975815832 To resize chart data range drag lower right corner of range
Page 48
Chart1 Anger
148
003
04
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
Page 49
Sheet1 Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
d Anger ImRs 148 Waitlist 003 STAIR 04 To resize chart data range drag lower right corner of range
Page 50
Treatments for borderline personality disorder
bull Also better effects when ndash there is a focus on representations (memories of
early adverse events) ndash experiential techniques are used
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 51
Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr
(81 studies N=6288)
Figure not shown due to embargo rules
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 52
bull But does focus on early adverse experiences and use of experiential techniques lead to higher dropout
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 53
Treatment for Borderline PD Retention by treatment model (1 year)
000
010
020
030
040
050
060
070
080
090
100
0 1 2 3 4 Quarter
ST
DBT
MBT
PsyDyn
DBTmin
TAU
TFP
SpecOther
CBT
CTBE
81 studies total N = 6288
Arntz et al Psychol Medicine in revision
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 54
ST for Borderline PD group or individual + group
bull Large international trialbull Preliminary data N=496bull Group-ST (with limited individual) vs
individual + group vs (optimal) TAUbull 3 year assessments year 3 no treatment (ST)
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 55
Treatment RetentionST-B superior to S-TAU and ST-A
Figure not shown due to embargo rules
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 56
Primary Outcome BPD-severityover 3 years
Figure not shown due to embargo rules
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 57
WHOQOLQuality of Life
Figure not shown due to embargo rules
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 58
Interpretation
bull Individual ST allows for extensive processing of childhood adverse eventsndash Very common in BPD
bull Individual ST offers individual attention support and secure attachmentndash Correction of early childhood experiences
NB patients and therapists tended to prefer combined individual-group format (Tan et al 2018 PlosOne)
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 59
Adaptations of CT protocols for complex cases
bull British development (Clark amp Ehlers) bull Addition of schema therapy-like methods when
standard protocol failsndash In CT for PTSD (ldquoupdating the trauma memoryrdquo by
imagery rescripting)ndash In CT for social phobia look for early experiences that
gave rise to the problem (eg bullying social exclusion) amp use imagery rescripting
bull Similar approaches for eating disorders OCD BDD
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 60
ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP
bull N=12bull 11 had previous CBT (m =
18 CBTrsquos)bull All could identify a memory
related to start of OCDbull Control = 1 session talking
about memorybull ImRs = 1 sessionbull Cohenrsquos d = 19 (YBOCS)
0
5
10
15
20
25
30
BL control ImRs 3-m FU
YBOCS
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 61
Chart1 YBOCS
248
241
16
107
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 62
Sheet1 Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you YBOCS BL 248 control 241 ImRs 16 3-m FU 107 To resize chart data range drag lower right corner of range
Page 63
Misunderstandings about trauma amp PTSDbull Relationship between specific traumas and a
specific syndrome (PTSD) is overestimatedndash Threats to body integrity can lead to other
disordersndash Other trauma than defined by DSM-5 PTSD
section can lead to PTSD symptoms (eg emotional abuse betrayal)
bull (Early) adverse experiences can lead to many forms of psychopathologyndash Sadly these are often not addressed when there is
no PTSD
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you Page 64
Limitations to focusing on underlying representations
bull Some problematic behaviours donrsquot change despite addressing underlying representations
bull Perhaps second order conditioningndash CS2 rarr CS1 rarr USndash Addressing US representation (US-revaluation)
and CS1 rarr US relationship does not affect CS2bull Specific techniques needed to address such
ldquoautonomousrdquo problemsbull Eg behavioral pattern breaking phase in ST
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you Page 65
Conclusionsbull CT became focused on reasoning errors and other
biasesbull To the expense of focus on representations underlying
the problembull Creates risks of incomplete cure amp relapsebull In many complex cases early experiences underlie the
(vulnerability) for the disorderndash Addressing these will improve treatment outcome (in the
long term)ndash C(B)T has to overcome resistance to this ldquopsychodynamic
thinkingrdquobull Use of experiential techniques recommended to more
fully address underlying representationsndash Verbal (rational) reasoning might not reach the full
representation
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you Page 66
Challenges for the futurebull Can we change the representation itself instead of
creating an alternative that competes with the originalndash If so no relapsendash Lab research possible with part of the fear memory by
combined biological-psychological procedure (Kindt et al)bull Diagnostic procedures to find the representation
underlying a problemndash Limited awarenessndash We can use procedures from nonverbal therapies
bull Speeding-up treatments for complex problems (eg personality disorders)ndash Perhaps earlier focus on memories of early adverse events
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you Page 67
Thank you
Further readingArntz A (2019) A plea for more attention
to mental representation Journal of Behavior Therapy amp
Experimental Psychiatry
Cognitive therapy for challenging problems overview History Habituation reduced response to stimulus with repetition Dishabituation increased response to stimulus after habituation Dishabituation orienting response Interpretation Development of Cognitive Therapy Early successes of Cognitive Therapy Problems with Cognitive Therapy Relapse after successful C(B)T for depression Relapse after successful depression treatmentDeRubeis Siegle amp Hollon (2008) Nature Reviews Neuroscience 9 788 Relapse after successful C(B)T for depression Relapse in 2 years (depression)based on Vittengl et al (2007) Clarke et al (2015) Relapse after successful C(B)T for depression Overlooked factors in CT for depression Imagery Rescripting vs CT for depression (Yuen Ting submitted) Low relapse after recovery PTSD Personality Disorders Continued improvement after STDickhaut amp Arntz 2012 Wetzelaer et al 2014 What is the difference Prediction Childhood-abuse PTSD treatments for adults effect size g meta-analysis Ehring et al Clinical Psychology Review 34 (2014) 645ndash657 ImRs vs STAIR+ImRs vs Wait for complex PTSD effect sizesRaabe et al in preparation Emotion Regulation (DERS pre-post) Guilt Shame Anger Cohenrsquos d (pre-post) Treatments for borderline personality disorder Multilevel Meta-analysis Hedgesrsquogchange in BPD-manifestations at 1 yr(81 studies N=6288) Lysbildenummer 28 Treatment for Borderline PD Retention by treatment model (1 year) ST for Borderline PD group or individual + group Treatment RetentionST-B superior to S-TAU and ST-A Primary Outcome BPD-severityover 3 years WHOQOLQuality of Life Interpretation Adaptations of CT protocols for complex cases ImRs for treatment-resistent OCDVeale Page Woodward amp Salkovskis (2015) BTEP Misunderstandings about trauma amp PTSD Limitations to focusing on underlying representations Conclusions Challenges for the future Thank you 
![· Aaron T. Beck Cognitive Behavior Therapy 100 âQUfiU (Cognitive Therapy) (Cognition) vnt]thðlå' 2 Cognitive Behavior Therapy nuntJQ{ Cognitive Behavior Therapy CEItJQtnnuCLâŸnu](https://static.documents.pub/doc/80x56/5e95f62359195604315efd8a/aaron-t-beck-cognitive-behavior-therapy-100-qufiu-cognitive-therapy-cognition.jpg)
