s the behaviortherapist...covid-19 is impacting how abctdoes busi-ness, but it’s not...

the Behavior TherapistI S S N 0 2 7 8 - 8 4 0 3

VOLUME 43, NO. 5 • JUNE 2020

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ABCT

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association forbehavioral andcognitive therapies

Contents

June • 2020 153

PRESIDENT’S MESSAGE

Living With COVID-19:How ABCT Is DealingWith the PandemicMartin M. Antony,Ryerson University

IT’S mAY 4, 2020. It seemsimportant to “date stamp” thiscolumn, since the landscapecontinues to change rapidly asthe current pandemic runs itscourse. I am well aware thatwhatever I might say now mayno longer seem as relevant in

June, when this issue is released. In this column,I highlight some of the ways in which ABCT isresponding to the COVID-19 crisis, and howCOVID-19 is impacting ABCT.

COVID-19 is also a focus of several other arti-cles in this issue of the Behavior Therapist.michelle Paluszek and colleagues provide anoverview of psychological processes related tothe spread of COVID-19, how people cope withpandemics, and how we are likely to adjust to apost-COVID world. Jason Krompinger and col-leagues provide suggestions for adapting expo-sure and response prevention for treating OCDin the age of COVID-19. Finally, AubreyDueweke and colleagues provide recommenda-tions for effectively engaging children and ado-lescents in remotely delivered mental health ser-vices. Rounding out this issue is an originalresearch article on promoting healthy parentingpractices.

Impact of COVID-19 on ABCTCOVID-19 is impacting how ABCT does busi-ness, but it’s not slowing us down. The ABCT

[Contents continued on p. 154]

President’s MessageMartin M. AntonyLiving With COVID-19: How ABCT Is Dealing Withthe Pandemic • 153

At ABCTMary Jane EimerFrom Your Executive Director • 156

SPECIAL ISSUE: COVID-19and Mental Health

Science ForumMichelle M. Paluszek, Caeleigh A. Landry, Steven Taylor,Gordon J. G. AsmundsonThe Psychological Sequelae of the COVID-19 Pandemic:Psychological Processes, Current Research Ventures, andPreparing for a Postpandemic World • 158

Clinical Practice ForumJason W. Krompinger, Jennie M. Kuckertz, Meghan Schreck,Jacob A. Nota, Nathaniel Van Kirk, Martha J. FalkensteinAdapting Exposure and Response Prevention in the Age ofCOVID-19 • 166

Aubrey R. Dueweke, Megan M. Wallace, Andel V. Nicasio, Bianca T.Villalobos, Juventino Hernandez Rodriguez, Regan W. StewartResources and Recommendations for Engaging Children andAdolescents in Telemental Health Interventions During COVID-19 and Beyond • 171

Original ResearchCarey Bernini DowlingChanges in College Students’ Opinions on Parenting:Undergraduate Education as Primary Prevention • 176

154

the Behavior TherapistPublished by the Association for

Behavioral and Cognitive Therapies305 Seventh Avenue - 16th Floor

New York, NY 10001 | www.abct.org(212) 647-1890 | Fax: (212) 647-1865

Editor: Richard LeBeau

Editorial Assistant: Resham Gellatly

Associate EditorsRaeAnn AndersonTrey AndrewsShannon BlakeyLily BrownAmanda ChueNajwa CulverBrian FeinsteinDavid HansenAngela morelandSamantha moshierAmy murrellAlayna ParkJae PuckettJennifer ReganAmy SewartTony Wellsmonnica WilliamsKatherine Young

ABCT President: Martin M. AntonyExecutive Director: Mary Jane EimerDirector of Communications:

David TeislerConvention Manager: Stephen CraneManaging Editor: Stephanie SchwartzMembership Services Manager:

Dakota McPherson

Copyright © 2020 by the Association for Behavioraland Cognitive Therapies. All rights reserved. No partof this publication may be reproduced or transmittedin any form, or by any means, electronic or mechan-ical, including photocopy, recording, or any infor-mation storage and retrieval system, without permis-sion in writing from the copyright owner.

Subscription information: tBT is published in 8issues per year. It is provided free to ABCT members.Nonmember subscriptions are available at $40.00 peryear (+$32.00 airmail postage outside NorthAmerica). Change of address: 6 to 8 weeks arerequired for address changes. Send both old and newaddresses to the ABCT office.

ABCT is committed to a policy of equal opportu-nity in all of its activities, including employment.ABCT does not discriminate on the basis of race,color, creed, religion, national or ethnic origin, sex,sexual orientation, gender identity or expression,age, disability, or veteran status.

All items published in the Behavior Therapist,including advertisements, are for the information ofour readers, and publication does not imply endorse-ment by the Association.

The Association for Behavioral and Cog-nitive Therapies publishes the BehaviorTherapist as a service to its membership.Eight issues are published annually. Thepurpose is to provide a vehicle for therapid dissemination of news, recentadvances, and innovative applications inbehavior therapy.

Feature articles that are approxi-mately 16 double-spaced manuscriptpages may be submitted.

Brief articles, approximately 6 to 12double-spaced manuscript pages, arepreferred.

Feature articles and brief articlesshould be accompanied by a 75- to100-word abstract.

Letters to the Editor may be used torespond to articles published in theBehavior Therapist or to voice a profes-sional opinion. Letters should be lim-ited to approximately 3 double-spacedmanuscript pages.

Submissions must be accompanied by aCopyright Transfer Form (which can bedownloaded on our website: http://www.abct.org/Journals/?m=mJournal&fa=TBT): submissions will not be reviewed with-out a copyright transfer form. Prior topublication authors will be asked tosubmit a final electronic version of theirmanuscript. Authors submitting materi-als to tBT do so with the understandingthat the copyright of the published mate-rials shall be assigned exclusively toABCT. Electronic submissions are pre-ferred and should be directed to theeditor, Richard LeBeau, Ph.D., [email protected]. Please include thephrase tBT submission and the author’slast name (e.g., tBT Submission - Smith etal.) in the subject line of your e-mail.Include the corresponding author’s e-mail address on the cover page of themanuscript attachment. Please alsoinclude, as an attachment, the completedcopyright transfer document.

INSTRUCTIONS Ñçê AUTHORS

At ABCTPatricia Marten DiBartoloNow more Than Ever: In Search of ABCT Leadershipin 2021 and Beyond • 183

Plus• Annual Convention Preview: Ticketed Sessions • 184

• ABCT Seeks Outreach & Continuing Education manager • 186

• Call for Nominations: Champions • 187

• Call for Nominations: mentors • back page

[Contents, continued]

GREG SIEGLE

In a discussion in which he lays out various elements that we do, or can,use to help us better address our patients’ needs, Greg Siegle points toneuroscience, mindfulness, dissemination and implementation, as well asbrain mechanisms, and manages to make it all visible, understandable,and come to life. Watch the interview here:

www.abct.org ABCT > FOR MEMBERS > CBT PIONEERS

A B C T P I O N E E R S S E R I E S

p r e s i d e n t ’ s m e s s a g e

central office is now working remotely, andthe Board’s June strategic planning retreat(originally scheduled as an in-person meet-ing in Philadelphia) will now occur virtually.Fortunately, the ABCT Board and leader-ship conducts much of its business remotelyanyway, so for much of what we do, it’s beenbusiness as usual during the pandemic.

You may be wondering what’s happen-ing with our Annual Convention. As youlikely know, many organizations have had tocancel or postpone their annual meetings asa result of the pandemic. Examples includemeetings of the Anxiety and DepressionAssociation of America, American Psycho-logical Association, American PsychiatricAssociation, Canadian Association of Cog-nitive and Behavioural Therapies, CanadianPsychological Association, InternationalAssociation of Cognitive Psychotherapy,and National Association of Social Workers,to name a few. At this point in time, theABCT convention is still planned forNovember. However, we are monitoring thesituation closely, and will make a decisionno later than the end of the summer aboutwhether to hold our Annual Convention inPhiladelphia. In case we are not able to meetin person, we are currently looking into

options for holding the conventionremotely. We are also investigating the pos-sibility of a hybrid convention, with optionsfor both in-person and remote participa-tion. Of course, we will consider local, state,and federal guidelines regarding large gath-erings and travel, as well as our members’level of comfort around meeting in person.The good news is that we received a largenumber of submissions, and our ProgramCommittee is putting together an excitingmeeting that will provide opportunities forcontinuing education, sharing cutting-edgeresearch, and networking with colleagues.We will be in touch with more informationas we have news to share about the format ofour convention.

ABCT’s Response to COVID-19When the pandemic hit North America,ABCT posted a COVID-19 statement on itswebsite, as well as links to resources onhealth-related information, coping withanxiety, using telehealth to provide services,and a range of other COVID-related topics.You can find these on our home page(www.abct.org/Home). The resourcesinclude websites, blogs, books, videos, pod-

casts, and other materials, covering a widerange of topics, such as:

• Information on the COVID-19pandemic

• Coping with anxiety and depressionin the context of COVID-19

• Best practices for telehealth• Teaching online classes• Parenting during COVID-19

The list of resources is updated regularly. Ifyou have any COVID-19-related resourcesto suggest for the website, please feel free tosend them along for consideration. Also,any suggestions for how ABCT can betterserve our members or the public during thisdifficult time are welcome. You can reachme at [email protected].

In the meantime, I hope that you and thepeople you care about stay well, both physi-cally and emotionally!

. . .

No conflicts of interest of funding to disclose.Correspondence to martin m. Antony, Ph.D.,Department of Psychology, Ryerson Univer-sity, 350 Victoria Street, Toronto, ON, m5B2K3, Canada; [email protected]

Helping Clients Transitionto the New Normal— Amelia Aldao, Ph.D.

11 am – 12:30 pm Eastern | 10 am – 11:30 pm Central9 am – 10:30 am Mountain | 8 am – 9:30 am Pacific

JUNE 19

$30 for ABCT membersCE Credit: 1.5

Webinarwww.abct.org/Conventions/?m=mConvention&fa=Webinars

RegisterNow!

As restrictions to physical distancing begin to lift inthe coming months, we are all facing an unprece-dented situation: on the one hand, we will be “goingback to normal,” but, on the other one, much haschanged over the past few months, so we will actu-ally living in a “new normal.” This juxtaposition offamiliar and new can be the source of much anxietyand distress, but it can also represent an opportu-nity to redefine ourselves and grow. As therapists,we have a unique opportunity to help our clientsnot only cope with these changes, but also thrive inthe face of this new life we’re about to start. In thiswebinar, I will discuss an emotion-focused CBTapproach for helping clients manage surges in anx-iety (e.g., worries about resuming in-person interac-tions, heightened fears of contamination, agora-phobic concerns, existential anxiety, hopelessness)and adopt a values-based approach to reenvisiontheir lives (e.g., career, relationships, health). I willreview a transdiagnostic approach, since clientsmight experience concerns that are not necessarilyaligned with their current diagnosis (e.g., someonewith social anxiety might become preoccupied withcontamination). It will be highly interactive (comeprepared with questions!) and we’ll also tackle self-care as therapists. For a full description, includinglearning objectives and recommended readings, goto:

http://www.abct.org/Conventions/?m=mConvention&fa=Webinars.

June • 2020 155

Dr. Aldao is a Licensed Clinical Psychologist with exper‐tise in CBT for anxiety and mood disorders. She is theFounder and Director of Together CBT, a clinic specializingin anxiety and stress in New York City. She is a VisitingScholar at Columbia University and on the PsychiatryFaculty at Mount Sinai Hospital, where she teaches CBT toGraduate Students in Clinical Psychology and Residents inPsychiatry, respectively.

156 the Behavior Therapist

Frustratingly, COVID-19 is still here impactingour daily lives andimmediate future. Fromthe postings on our listserve, meetings held viaZoom, and emailsreceived from individual

members, this is clearly an innovative andresilient membership. The ever-presenttheme has been a “can-do attitude” toaddress every challenge that comes ourway. The leadership, staff, and individualmembers have queried how do we best helpthe general public; how do we help ourmembers transition from face-to-face ther-apy sessions to telehealth; how do wesupervise students and interns; how do weteach remotely, immediately; how do wecare for front-line health workers who maynot have health insurance? Staff has beenreading the list serve postings and contact-ing those of you willing to share yourexpertise and resources without amoment’s hesitation.

Early on, the Board opted to highlightscience in our efforts to reduce COVID-19’s impact. They did that by emphasizinghand-washing; involving our kids in dis-cussions, so they get to hear facts and aren’tleft to their own unchecked fears or imagi-nations; and limiting exposure, both to thevirus and to media coverage of it. They alsobegan linking to the few resources we had,such as CDC, WHO, and Health Canada.The numbers, and types, of resources havegrown, and we’ve added topic heads—Health Information, Resources for Anxi-ety, Telehealth, and Coping in the RealWorld—as more became available. Someare links to trusted sites while others arevideos developed specifically for issuesimpacted by the pandemic. Especiallynoteworthy are Kate morrison’s primer onproviding telehealth and everything oneneeds to know to begin teaching online.And we even have some forward thinkerswho are providing tips to help you returnto normalcy, hopefully in the not-too-dis-tant future. You can find this at http://

www.abct.org/Information/?m=mInfor-mation&fa=COVID19

Kate Gunthert, membership IssuesCoordinator, in cooperation with DaniellaCavenagh, Chair of our Clinical Directoryand Referral Issues, undertook an initiativeto get our members who were taking onnew clients and transitioning to telehealthto identify themselves. We’ve gone from 54to 222 members providing telehealth sincemid-march. It’s easy for you to add your-self to our referral list if you are licensedand take referrals. Our next move was toask all members to post on their personalsocial media outlets:

Accessibility of mental health care is par-ticularly important in this time period.many people need to access mental healthservices via telehealth. I thought I’d share alink to one of the places I look for cogni-tive-behavioral care providers, the Associ-ation for Behavioral and Cognitive Ther-apy’s Find a CBT Therapist Directory:http://www.findcbt.org/FAT/. Therapistsin this directory have been updating theirprofiles to reflect whether telehealth is anoption (there is a telehealth search term onthe main search page). Thank you.

The leadership is gearing up for our trian-nual strategic planning retreat in earlyJune. What better time to discuss ourfuture than in confinement during a pan-demic? Our world is growing smaller andchange is coming faster. We need toaddress the future now so ABCT is ready interms of resources, technology, leadership,and staffing. The Board and our coordina-tors will be discussing the trends they areseeing in research, academia, and practiceand how this influences the services andbenefits we offer you, our membership. Wehired a consultant, Jeff De Cagna of Fore-sight First, LLC, to help us address thesetrends. He sent an environmental scansurvey to all members of governance,including our 40 Special Interest Groupleaders and members of the Task Force toPromote Equity, Access, and Inclusion. In

consultation with President Antony andPresident-Elect Tolin, we also put togethera smaller survey and sent it to nonmembersrecommended by Board members and sev-eral past presidents representing differentdisciplines: psychology, psychiatry, andsocial work. This feedback will set the stagefor our virtual retreat.

We are already experiencing the impacttechnology has on our personal and profes-sional lives. One of the biggest challengeswe are facing now is our Annual Conven-tion—business as usual (I don’t think so),totally virtual (maybe), or a hybrid (a likelychoice given our partnership with the hos-pitality industry). Staff is looking at thealternatives and more will be shared whenwe have a better understanding of the alter-natives available along with state and fed-eral restrictions regarding social distanc-ing. We are well aware of the need formembers to continue to build their CVs;hone their presentation skills; networkwith peers in their specialty area(s); earncontinuing education credits; and maintainprofessional friendships. We are consider-ing multiple ways we can recognize youraccomplishments while keeping you safe.

We are very pleased by the responsereceived to our prerecorded webinars for$15 for members and nonmembers. Giventhat we are still in confinement, we are con-sidering extending this promotion untilAugust 31, and have reduced the cost of thewebinar in June. Please check our websiteand list serve for updates.

June is also the month we begin gearingup for the November election. In this issueof tBT, there is an article from PatriciaDiBartolo, our Leadership and ElectionsCommittee Chair, outlining the processalong with a Call for Officer Nominations.The nomination form is included in thearticle and available on our website underElections. I urge you to nominate a col-league or yourself, self-nominations arewelcomed, for either the 2021-2022 Presi-dent-Elect; 2021-2024 Representative-at-Large and liaison to Convention and Edu-cation Issues; and the 2022-2025Secretary-Treasurer. ABCT is a member-driven organization and your active partic-ipation in needed and appreciated.

Stay safe, everyone. Until next time!

. . .

Correspondence to mary Jane Eimer, CAE,Executive Director, ABCT, 305 SeventhAve., Suite 1601, New York, NY 10001;[email protected]

AT ABCT

From Your Executive Director:What Your Leadership and StaffAre Working on to Serve You BetterMary Jane Eimer, Executive Director

June • 2020 157

Advances inPsychotherapyEvidence-Based Practice

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Each book is a “how-to” reference on a particular disorder.The books all have a similar structure, and each title is acompact and easy-to-follow guide covering all aspects ofpractice that are relevant in real life. Tables, boxed clinical“pearls,” and marginal notes assist orientation, whilechecklists for copying and summary boxes provide tools foruse in daily practice.

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THE NOVEL CORONAVIRUS disease, knownas COVID-19, arose in Wuhan, China inDecember of 2019. As of may 4, 2020, thevirus has infected over 3.4 million peopleand led to over 239,000 deaths globally(World Health Organization, 2020a), andthe numbers continue to rise exponentially.The World Health Organization declaredCOVID-19 a pandemic on march 11, 2020.In response to the COVID-19 pandemic,governments have imposed unprecedentedchanges, such as closures of all nonessen-tial business and mandated self-isolation.Health officials have also recommendedsocial distancing, avoidance of crowdedareas, and increased hygiene practices inattempt to reduce the spread of COVID-19(World Health Organization, 2020b). Themagnitude of the situation is further high-lighted by the unabating news and mediarevolving around COVID-19.

As a consequence of the threat of infec-tion, life has become characterized byfinancial uncertainty, fear, stress, and othersubstantial lifestyle changes (e.g., socialwithdrawal, isolation) that may increaserisk for mental health problems. Indeed,emerging empirical evidence from Chinaindicates that greater than 25% of the gen-eral population are currently experiencingmoderate to severe levels of anxiety inresponse to COVID-19 (Qiu et al., 2020;Wang et al., 2020). Although the full scaleof the psychological impact is not yetknown, based on observations from priorpandemics (Shultz et al., 2008; Taylor,2019a), it is anticipated to be larger than thephysical impact of the COVID-19 pan-demic. Efforts directed at minimizing thespread of COVID-19 and managing its

psychological sequelae are timely and crit-ical.

While much remains unknown aboutresponses to COVID-19, existing researchon past global outbreaks (e.g., SARS, Ebola,swine flu), which is reviewed in detail byTaylor (2019a), may be relevant and infor-mative in this regard. Empirical evidencefrom previous pandemics indicates thatpsychological factors play an instrumentalrole in infectious disease mitigation, socialdisorder, and vulnerability to mental healthproblems associated with pandemics(Taylor, 2019a). Investigating psychologi-cal factors influencing behavioral and emo-tional responses to COVID-19 is, there-fore, key to reducing the impact ofCOVID-19.

The current paper is structured to pro-vide an overview of the potential influenceof media broadcasting, psychologicalmechanisms involved in disease avoidance,and psychological traits potentially impli-cated in responses to COVID-19. Thesefactors are discussed in greater detail byTaylor (2019a). We then describe currentpsychological research on COVID-19 andour ongoing research program aimed ataddressing gaps in understanding of psy-chological processes and traits that influ-ence behaviors and emotional distressrelated to COVID-19. To conclude, a dis-cussion of expectations for the postpan-demic period and implications for thedelivery of CBT is provided.

The Role of MediaPeople are being inundated with infor-

mation related to COVID-19 through newsand social media outlets. Indeed, the World

Health Organization (2020c) has describedthe current state of the COVID-19 pan-demic as a “massive infodemic.” massmedia, through the use of emotionallycharged language and images, can have aprofound influence in exaggerating theperceived dangers associated with infec-tious disease (Kilgo et al., 2018: muzzati,2005). Consequently, the media may thenexacerbate individual inclinations towardsfear or indifference. While it is importantthat the public remain informed about thepandemic (e.g., current government regu-lations, public health recommendationsand actions), prolonged media exposurecan also lead to “media fatigue,” in whichindividuals become desensitized to themedia and potentially disregard importantinformation (Collinson et al., 2015). Fur-ther compounding the issue is the abun-dance of misinformation that may causeincreased anxiety as people may not knowwhich sources of information are reliable(Taylor, 2019a).

Government communication throughthe media during a pandemic is a powerfulsource of influence (Devakumar et al.,2020). On the one hand, transparent andclear messaging can relieve anxiety anduncertainty by providing the public withaccurate and up-to-date information onthe state of the pandemic (Eaton & Kalich-man, 2020; Taylor 2019a). On the otherhand, the use of xenophobic language,inconsistent information, and suggestionof government conspiracies has the poten-tial to give rise to public fear and division. Itis of the utmost importance that govern-ments carefully construct messages incoordination with other officials to deliveran effective, cohesive message to the publicon COVID-19 (Kapiri & Ross, 2020).

Behavioral Immune SystemDue to the microscopic nature of viral

pathogens, an individual’s biologicalimmune system is only reactive to infectionand insufficient to prevent infection(Duncan & Schaller, 2009; Taylor, 2019a).As such, the behavioral immune system(BIS) has evolved to mobilize in responseto the threat of infection. The BIS is a com-plex system involved in detecting andresponding to perceived indicators of thepresence of an infectious disease (e.g.,someone coughing or sneezing; Ackermanet al., 2018; Schaller & Park, 2011). The BISfurther elicits emotional reactions (e.g., dis-gust, fear, anxiety) to facilitate behavioralavoidance of virus-relevant cues and pre-

SCIENCE FORUM

The Psychological Sequelae of the COVID-19Pandemic: Psychological Processes, CurrentResearch Ventures, and Preparing for aPostpandemic WorldMichelle M. Paluszek* and Caeleigh A. Landry,* University of Regina

Steven Taylor, University of British Columbia

Gordon J. G. Asmundson, University of Regina

* contributed equally to this article

June • 2020 159

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p a l u s z e k e t a l .

vent contact with potential pathogens(Schaller & Park).

The cues detected by the BIS are onlysometimes indicative of infection (Schaller& Park, 2011). To ensure protection, theBIS tends to generate false-positive errorsin that it may incorrectly perceive a cue toindicate infection when it is not present.Further, there are individual differences inthe sensitivity of the BIS (Duncan &Schaller, 2009; Duncan et al., 2009). Someindividuals may be especially sensitive orattentive to the presence of cues that maysuggest pathogens and such cues elicit amore intense reaction. Individuals withhigher levels of perceived vulnerability toinfection and disgust sensitivity reflect thisphenomenon.

Disgust SensitivityDisgust sensitivity—the extent to which

an individual experiences emotional dis-tress and repulsion from disgust-inducingstimuli—is proposed to be an indicator of asensitive BIS (Goetz et al., 2013; Taylor,2019a). Disgust may be elicited throughtaste, sight, or smell (Terrizzi et al., 2010).Sick or unhygienic people, bodily content,and dirty environments are examples ofproposed universal disgust-inducing stim-uli (Curtis et al., 2011). Individuals withheightened disgust sensitivity tend to reactmore intensely to disgust-inducing stimuli.A similar reaction may be elicited by stim-uli that resemble, or come into contactwith, disgust-inducing stimuli (Curtis etal.; Oaten et al., 2009; Rozin et al., 2008).Disgust sensitivity has been found to beinvolved in the development and mainte-nance of certain phobias (e.g., spiderphobia, blood-injection-injury phobia;Olatunji, 2006; Olatunji et al., 2006) as wellas contamination-based obsessive-com-pulsive disorder (Olatunji et al., 2005).

Empirical evidence implicating disgustsensitivity in pandemic-related reactionshas been emerging. Disgust sensitivity hasbeen found to predict greater fear of infec-tious disease (e.g., Ebola; Blakey et al., 2015;Brand et al., 2013; Wheaton et al., 2012). Arecent study also suggests that disgust sen-sitivity may interact with the physical con-sequences factor of anxiety sensitivity (AS;referred to below) to predict greater con-cern of infection from an infectious disease(mcKay et al., in press). Disgust sensitivitymay be a relevant trait to consider for dif-ferentiating who may be at risk for greaterCOVID-19-related anxiety or fear.

Perceived Vulnerability to DiseasePerceived vulnerability to disease

(PVD) refers to the individual’s belief ofhow likely they would be to contract aninfectious disease (Taylor, 2019a). The BISis particularly sensitive in individuals withhigh PVD. An individual with high PVD ismore likely to perceive a disease as a threatand have an anxious emotional and behav-ioral reaction. For this reason, it is believedthat those with elevated PVD are likely toexperience high levels of emotional distressduring a pandemic (Taylor). The trait mayalso partly account for the drive to avoidgroups who are perceived to be likelyinfected with COVID-19.

As infectious diseases are often trans-mitted through social contact, theoristspropose that the BIS evolved to influenceattitudes and social interactions in attemptto avoid infection (Schaller & Park, 2011).This influence may come in the form ofxenophobia (i.e., prejudice towards for-eigners; Schaller & Park). When threatenedby an outbreak, individuals who are highlymotivated to avoid infection may exhibitxenophobia due to the belief foreigners aresources of infection. Studies indicate thatindividuals with elevated PVD are mostlikely to endorse negative attitudes towardsforeigners and avoid contact with foreign-ers (e.g., Aarøe et al., 2017; Duncan et al.,2009; Faulkner et al., 2004).

The avoidance, stigmatization, andblame of out-groups (i.e., groups one doesnot belong to) is not an uncommon reac-tion to the threat of an infectious disease(makhanova et al., 2015; Taylor, 2019a).Evidence of xenophobia was observedduring SARS and the Bubonic Plague(Cohn, 2010; Washer, 2004). Xenophobiadirected at individuals of Chinese ancestryis being reported during the COVID-19pandemic (e.g., Aguilera, 2020). Discrimi-nation may not only hinder joint efforts tomitigate the spread of infectious disease,but also create undue distress for out-groups (Taylor). marginalized groups mayalready find themselves vulnerable duringthe COVID-19 pandemic for a number ofreasons. For example, members of margin-alized groups may be less likely to seek outor afford health care services, may lackfinancial resources to effectively self-isolateas per recommendations, or may be morelikely to have preexisting chronic healthconditions that increase risk of COVID-19-related complications (Eaton & Kalich-man, 2020; Hutchins et al., 2009; Smith &Judd, 2020; Yancy, 2020). The pandemicmay further drive social, financial, and

health care disparities experienced by mar-ginalized groups, putting them at evengreater risk of physical and mental healthproblems (Eaton & Kalichman; Yancy).The implementation of comprehensiveinterventions directed at addressingCOVID-19-related fear, xenophobia, andsocioeconomic inequalities are needed tobolster the protection of vulnerable groupsduring the COVID-19 pandemic.

Psychological TraitsTo slow the spread of infection, com-

munities will have to work collectively inaccordance with public health recommen-dations. Health officials are currentlyencouraging social distancing and properhygiene behaviors (e.g., handwashing) andwill likely recommend all eligible individu-als receive a COVID-19 vaccine when theybecome available (World Health Organiza-tion, 2020b); however, not everyone will bewilling to engage in such behaviors. Someindividuals may magnify infection risk byengaging in maladaptive behaviors (e.g.,failing to wash hands, maintain social dis-tancing, or receive a vaccine). Other indi-viduals might react to COVID-19 withmoderate fear, motivating them to adhereto recommendations, while others mayexperience intense and debilitating fear.Below we address individual difference fac-tors that may influence anxiety and stressresponses and their possible downstreameffects on adaptive or maladaptiveCOVID-19-related behaviors.

Unrealistic Optimism BiasUnrealistic optimism bias is the ten-

dency to have overly positive beliefs aboutone’s future (Taylor & Brown, 1988).People who have an unrealistic optimismbias tend to believe that positive events aremore likely to happen to them than toothers and, as such, underestimate the dan-gers of disease and other potential threats(Weinstein, 1980). During the SARS out-break, those with unrealistic optimism biasbelieved themselves to be less likely to con-tract the infection than others (Ji et al.,2004). Individuals with unrealistic opti-mism bias may pose a serious societalthreat during pandemics as they areunlikely to practice proper preventativehealth behaviors, such as proper hand-washing and vaccination (Taylor, 2019a).

Unwillingness to vaccinate, even in aminority of individuals, can have sizeablerepercussions on the public (World HealthOrganization, 2020d). Efforts to eradicatethe disease through vaccine distribution

June • 2020 161

p s y c h o l o g i c a l s e q u e l a e o f c o v i d - 1 9 p a n d e m i c

Celebrat ing Our 48th Year

Steven T. Fishman, Ph.D., ABPP | Barry S. Lubetkin, Ph.D., ABPPDirectors and Founders

Since 1971, our professional staff has treated over 30,000 patients with compassionate, empirically-based CBT.Our specialty programs include: OCD, Social Anxiety Disorder, Panic Disorder, Depression, Phobias, PersonalityDisorders, and ADHD-Linked Disorders, and Child/Adolescent/Parenting Problems.Our externs, interns, post-doctoral fellows and staff are from many of the area’s most prestigious universitiesspecializing in CBT, including: Columbia, Fordham, Hofstra, Rutgers, Stony Brook, St. John’s, and YeshivaUniversities.

Conveniently located in the heart of Manhattan just one block from Rockefeller Center. Fees are affordable,and a range of fees are offered.

New York CityINSTITUTE for BEHAVIOR THERAPY

For referrals and/or information, please call: (212) 692-928820 East 49th St., Second Floor, New York, NY 10017e-mail: [email protected] | web: www.ifbt.com

may be diminished. Contention arisingfrom opposing views on vaccine accept-ability (e.g., potential use of “vaccinationcertificates” to allow travel) could alsoincite societal discord and strife. In addi-tion to unrealistic optimism bias, otherpsychological traits (discussed furtherbelow) may influence vaccine hesitancy.For example, individuals with high intoler-ance of uncertainty (IU) or health anxietycould be concerned about the potentialunknown side effects of a vaccine and, thus,be unwilling to receive it (Petrie et al., 2004;Taylor, 2019a).

Health AnxietyThe tendency to become distressed by

illness-related stimuli (e.g., fever, cough-ing) is known as health anxiety(Abramowitz & Braddock, 2011; Asmund-son & Taylor, 2020a; Taylor & Asmund-son, 2004). Both high and low levels ofhealth anxiety are associated with mal-adaptive behaviors. Those with low healthanxiety are unlikely to engage in recom-mended hygiene behaviors and are espe-cially vulnerable to unrealistic optimismbias (Gilles et al., 2011). Previous studies ofprior epidemics indicate that individuals

with low health anxiety are least likely toadhere to social distancing and to washtheir hands as per recommendations(Goodwin et al., 2009; Jones & Salathe,2009; Rubin et al., 2009; Williams et al.,2015; Wong & Sam, 2011). On the otherhand, those with elevated heath anxietytend to worry excessively about their healthand can overestimate the degree of threatposed by an illness (Hedman et al., 2016;Taylor & Asmundson, 2004; Wheaton etal., 2010), including COVID-19.

People with high health anxiety arelikely to overuse health care services andexperience high levels of impairment whenexperiencing a perceived threat (Bobevski,et al., 2016; Eilenberg et al., 2015; Sunder-land et al., 2013). They are often hypervigi-lant towards their bodily sensations andmore likely to interpret those symptoms asdangerous (Tyrer & Tyrer, 2018). Due tothe widespread media coverage of COVID-19, people may begin paying closer atten-tion to bodily sensations that they wouldhave previously ignored. Self-isolation mayalso worsen health anxiety, as environ-ments with low external stimuli may facili-tate awareness of internal stimuli (Taylor &Asmundson, 2004).

Anxiety SensitivityConceptually similar to health anxiety,

AS is the fear of anxiety or arousal-relatedreactions (e.g., rapid heartbeat, shortness ofbreath) based in the belief that these reac-tions are harmful or bring about negativeconsequences (e.g., death; Reiss &mcNally, 1985; Taylor, 2019b). Health anx-iety and AS share an overarching fear ofbodily changes or sensations and misinter-pretation of these changes or sensations asdangerous (Taylor, 2019a). When an indi-vidual with heightened AS experiencesnormal bodily sensations (e.g., when anx-ious), anxiety and the acquired fearresponse to these sensations are magnified(Taylor et al., 2007). AS is purported toincrease risk for a range of disorders,including anxiety-related disorders (Bern-stein et al., 2005; Schmidt et al., 2006; Tullet al., 2009). Elevated AS, particularly relat-ing to concern of physical consequences(e.g., heart attack), may also increase riskfor pandemic-related anxiety and certainbehavioral patterns (Blakey et al., 2015;Taylor, 2019a). The physical consequencesfactor of AS has also been shown to medi-ate the relationship between obsessive-



compulsive symptoms (e.g., checking,washing) and fear of swine flu (Brand et al.,2013). Further research is necessary to elu-cidate the potential role of AS in COVID-19-related anxiety and disease-mitigatingbehaviors.

Intolerance of UncertaintyIU is another trait factor that may have

important consequences for COVID-19-related coping. IU refers to the individual’sability to handle missing information andfeelings of uncertainty that may accom-pany it (Carleton, 2016). People with highIU prefer predictability in their lives andcan feel paralyzed with indecision whenfaced with an unexpected situation (Birrellet al., 2011). High IU has been found tocontribute to a variety of mental healthconditions and to be linked to the develop-ment of excessive worry (Gentes & Ruscio,2011; Rosser, 2018; Shihata et al., 2016).Individuals with elevated IU may perceiveCOVID-19 as a particularly distressingtime given its many unpredictable situa-tions and unknowns, including, but notlimited to, contracting the virus, perceivingwho is infected, what could be carrying thevirus, how to protect oneself or loved ones,as well as potential job loss (Taylor, 2019a).Additionally, high IU has been associatedwith health-related checking and reassur-ance seeking (Dugas & Robichaud, 2007).Similar to health anxiety (Asmundson &Taylor, 2020a, 2020b), the need for confir-mation that one is free of infection maymotivate those with higher IU to contactmedical services even with relativelybenign symptoms and consequently over-burden the health care system. There ispotential that the news media may furtherfuel uncertainty, especially given that thereis still much to learn about COVID-19.

Current Findings andOngoing Research

At present, limited research has beenpublished on the psychological factorsinvolved in the COVID-19 pandemic.Cross-sectional population studies fromChina suggest substantial anxiety anddepression during the initial stage of theCOVID-19 pandemic (Qiu et al., 2020;Wang et al., 2020). One study on collegestudents in China indicated that 25% of thestudents were experiencing mild to severelevels of general anxiety and that those whoknew someone infected with COVID-19were particularly distressed (Cao et al.,2020). Health care workers also appear tobe especially at risk of poorer mental health

outcomes. Significantly high rates of mildto severe symptoms of depression (50%),anxiety (45%), and insomnia (34%) werereported in one study (Lai et al., 2020).Another study indicated that front-linehealth care workers in China are more atrisk than nonclinical staff to experiencegeneral fear and symptoms of anxiety anddepression (Lu et al., 2020). Studiesdirected at understanding psychologicalfactors are still ongoing as the COVID-19pandemic continues to unfold; for exam-ple, the montreal Behavioural medicineCentre is conducting the InternationalCOVID-19 Awareness and ResponsesEvaluation, a longitudinal online study.While there are a number of researchgroups working to understand the psycho-logical impacts of COVID-19, the evidenceto date is limited by focus on general mea-sures of anxiety or narrow conceptualiza-tions of COVID-19-related fears. Thebreadth of COVID-19-related distress mayprove to be quite expansive.

Our own international research team isconducting a large-scale population repre-sentative study in Canada and the UnitedStates using online survey methodologyacross three time points (baseline, 1 month,and 3 months) to examine various psycho-logical traits and COVID-19-related dis-tress. Data from the first wave, comprising6,854 respondents, has been used in thedevelopment and initial validation of theCOVID Stress Scales (CSS; Taylor et al.,2020), comprising 36 items on five scalesassessing COVID danger and contamina-tion fears, COVID fears about economicconsequences, COVID xenophobia,COVID compulsive checking, and COVIDtraumatic stress symptoms. The CSS offerpromise as tools for better understandingthe psychopathology associated withCOVID-19 and for identifying people inneed of mental health services due to theCOVID-19 pandemic in particular andfuture pandemics in general. We are alsodeveloping an online self-assessment plat-form that, based on feedback from CSSself-assessment, individuals will be offeredtailored resources to help them better copewith pandemic-related distress. Futurewaves of our data collection will give aclearer indication of the mental healthlandscape as the pandemic evolves overtime and will help inform efforts to combatCOVID-19 as well as anticipated fallouts inthe postpandemic era.

Preparing for the Postpandemic EraThere are numerous ways in which life

may change as a result of the COVID-19pandemic, and there are currently manyuncertainties. It is not clear, for example,whether COVID-19 will disappear fromthe population, as did SARS, or whetherCOVID-19 will become a seasonal infec-tion, analogous to seasonal influenza. Butwe can be fairly certain that the currentpandemic will eventually end. There arevarious subtle ways in which the lives ofmany people will be changed by the pan-demic. These are discussed in detail byTaylor and Asmundson (2020). In theremainder of the present article, we focuson the implications for mental health prac-titioners.

Although the staggering infectiousimpact of COVID-19 may soon subside,clinicians will be faced with the challenge ofmanaging the anticipated pervasive surgeof mental health concerns. Early evidencefrom China at the onset of the pandemicsuggests an increase in general mentalhealth problems, including anxiety anddepression (Qiu et al., 2020; Wang et al.,2020). Stressors related to COVID-19 (e.g.,quarantine, unemployment, financialhardship, marital strain, isolation, socialwithdrawal, death of loved ones) will likelyinitiate or exacerbate mental health prob-lems (Brooks et al., 2020; Shultz et al., 2015;Taylor, 2019a). Some individuals infectedwith COVID-19 may suffer persistent psy-chological distress, as was found with SARS(Hong et al., 2009). Among front-linehealth care workers, there may be pro-found distress from burnout due to anexcessive workload and moral injuriesduring the pandemic (Williamson et al.,2020). Further, front-line health care work-ers may be at an elevated risk for experi-encing traumatic stress symptoms relatedto exposure to illness and death (Shultz etal., 2015; Taylor, 2017), as was the case withSARS (Naushad et al., 2019; Wu et al.,2009). As governments ease restrictions,stressors will involve readjusting lifestyles,coping with the potential threat of anotherwave of COVID-19, and residual anxiety inthe absence of an illness threat. While somemay attempt to resume their previouslifestyle, others (e.g., those who are intro-verted, health-anxious) may remain inseclusion to shelter from the world, similarto agoraphobia or hikikomori (i.e., socialwithdrawal lasting greater than 6 months;Teo, 2010). At present, the current mentalhealth care structure is ill-prepared to dealwith the need for psychological services

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brought upon by COVID-19. There is anurgent need for available, quality mentalhealth services tailored for the distress,lifestyle changes, and needs of the currentand postpandemic society.

Telehealth, also referred to as telemedi-cine, and online psychotherapy are well-poised to respond to the growing demandfor services that are accessible from home.Videoconferencing psychotherapy may bean efficacious alternative to face-to-facetherapy (Berryhill et al., 2019). Likewise,there is strong empirical evidence to sup-port therapist-guided and unguided inter-net-delivered CBT for general mentalhealth issues as well as a range of mentaldisorders (Andersson, 2016; Andrews etal., 2018; Hadjistavropoulos et al., 2016;Karyotaki et al., 2017). There is anticipa-tion that COVID-19 may serve as the cata-lyst for the widespread acceptance and pro-vision of online- or telehealth-deliveredpsychotherapy (Wind et al., 2020). How-ever, it is very likely that currently onlineprograms will require tailoring to addressthe mental health impacts specific toCOVID-19, at least in the most severelyimpacted. For example, it may be necessaryto provide mental health services in astepped- or blended-care approachwhereby those with minor issues receive anonline or app-delivered COVID-19-spe-cific health information intervention, thosewith moderate issues receive a similarlyfocused and delivered self-managed inter-vention, and the most severely impactedare treated with a similarly focused inter-vention that also includes individualcoaching via telephone or text. Such inter-ventions for COVID-19-specific distressare currently in the development and test-ing stages.

ConclusionThe COVID-19 pandemic is antici-

pated to have a pervasive impact on theactions and well-being of society as a con-sequence of a combination of substantial,widespread individual and societalchanges, media exposure, and preexistingpsychological traits and mechanisms.Research is needed to not only assess theextent of this concern, but also to informrecommendations that ensure appropriatetreatment. Fortunately, this research isunder way in various countries. Cliniciansare urged to adapt and reform currentpractice in line with evidence-based, acces-sible clinical practice. Government officialsand health care practitioners should make

efforts to prepare for the unknown andpotentially long-standing imprint ofCOVID-19 on the mental health and well-being of the current generation.

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Williamson, V., murphy, D., & Greenberg,N. (2020). COVID-19 and experiences ofmoral injury in front-line key workers.Occupational Medicine.

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. . .

Preparation for this paper was supported inpart by the Canadian Institutes of HealthResearch Canadian 2019 Novel COVID-19Rapid Research Funding Opportunity andthe University of Regina. Dr. Taylor receivesfinancial support through payments fromvarious book publishers and as part of hiswork as Associate Editor of the Journal ofObsessive-Compulsive and Related Disorders.Dr. Asmundson is the Editor-in-Chief of theJournal of Anxiety Disorders and Develop-ment Editor of Clinical Psychology Review.He receives financial support through pay-ments for his editorial work on the afore-mentioned journals and royalties from vari-ous book publishers.Correspondence to Gordon J. G. Asmund-son, Ph.D., Department of Psychology, Uni-versity of Regina, Regina, Saskatchewan, S4S0A2; [email protected]


THE COVID-19 PANDEmIC has affectedmost people on the planet. This article waswritten to address how it has specificallyaffected the clinical decision making ofthose who treat individuals with obsessive-compulsive disorder (OCD). OCD is char-acterized by recurrent, persistent, and dis-tressing thoughts, images, or urges (i.e.,obsessions) which drive maladaptivebehaviors that are carried out as a means ofeliminating that distress (i.e., compulsions,or rituals). While the compulsions provideshort-term relief, they simply reinforce theobsessions and create a situation whereinthe patient is robbed of opportunities toconfront their fears and come to rely on thecompulsions to navigate their world. Thegold-standard approach to treatment,exposure and response prevention (ERP),involves patients confronting their fearsrepeatedly while resisting engaging in com-pulsions. A simple example is a patientdeliberately coming into contact witheveryday items they deem “contaminated”and resisting efforts to wash their hands orotherwise remove the contaminant. Giventhe new reality that we all traverse, it maybe necessary for clinicians to make adjust-ments to the ERP approach in particularcircumstances.

This article, written by psychologistswho specialize in treating those with OCD,will review key principles to bear in mindwhen clinicians are considering modifyingtheir approach to exposure therapy amidstthis public health crisis. We will reviewconsiderations on both the exposure andprevention fronts, helping patients distin-guish between following guidelines andcarrying out compulsions, targeting corepsychological processes, leveraging theunique advantages of telehealth, and bear-ing in mind the effect of the pandemic onclinicians themselves. These recommenda-tions emerge as a result of extensive clini-cal experiences with the heterogeneity and,importantly, adaptability of OCD, asobserved both before and during the pan-demic. We would emphasize that while

these principles are empirically supported,we do not yet have the evidence base tosupport the efficacy of specific recom-mended adjustments.

Finally, we would note that the currentpandemic also carries implications forindividuals who struggle with illness anxi-ety disorder. While the two disorderslargely overlap, illness anxiety can be dis-tinguished from OCD on the basis thatthose with the former tend to focus moreon bodily sensations, have less awareness ofthe irrationality of their fears, and engagein maladaptive responses to their anxietythat is more based in reality (scouring med-ical websites; seeking persistent consulta-tion/reassurance from health care profes-sionals) than is sometimes the case withOCD (engaging in tapping, counting, orother superstitious behaviors to preventthe onset of an illness). While some of therecommendations here are relevant tothose with illness anxiety, the focus of thearticle will be OCD.

Amid Restricted Exposures,Emphasize Response Preventionmany of the traditional approaches to

implementing ERP for contamination-related symptoms run in direct contrast toCenters for Disease Control (CDC) guide-lines around managing risk of exposure tothe virus. Standard contamination-focusedexposures commonly include touchingpublicly used items such as doorknobs,light-switches, toilet levers, and sink han-dles and cross-contaminating to one’s bodyand face. Also common are exposures suchas touching the bottom of one’s shoes, sit-ting on floors, handling garbage, and usingpublic transportation. Postexposure wash-ing behaviors have strict limitations tofoster new learning around the perceivedcontaminant, resultant anxiety, and ritual-istic behavior. Although specific ap-proaches can vary by provider, standardERP procedures recommend setting firmlimits on handwashing such that it is

restricted to only following bathroom useor prior to eating, or if hands are visiblysoiled. Even still, these restrictions canbecome tighter depending on the specificsymptom presentation. For example, apatient with no capacity to tolerate notwashing their hands after using the bath-room might be encouraged to occasionallyresist handwashing altogether.

These standards for ERP came about, inpart, as a result of acknowledging the dis-tinction between probability and possibil-ity, and the evidence that OCD is charac-terized by an overestimation of threat(Carr, 1974; Salkovskis & Warwick, 1988).That is, although it is possible that engag-ing in exposures like those described canresult in illness, the probability is lowerthan the perceived threat. Further, in theevent that engaging in such exposures didresult in illness, they likely did not result inthe individual’s feared outcome occurring(e.g., slow, painful decompensation anddeath).

In the midst of the COVID-19 crisis,these variables have changed. Although it isstill statistically unlikely that an individualfollowing basic precautions will die fromthe disease, estimates during the peak ofcommunity spread suggest that the likeli-hood of becoming infected is relativelyhigh. Given the high rates of transmission,wide variation in symptom presentation,and preponderance of individuals vulnera-ble to the disease (including the elderly andthose with underlying medical conditions),the probability of creating harm by engag-ing in ERP as usual is categorically higherthan it was prior to this outbreak. Theintention of ERP is to learn something newabout one’s capacity to navigate perceivedthreats, rather than deliberately con-fronting actual threats (which is why dri-ving blindfolded, licking used petri dishes,or jumping into a pit of snakes would notconstitute appropriate exposures). There-fore, adjustments to our approach are nec-essary.

Because of this, where standard expo-sures may introduce higher than normalrisk, we suggest that providers focus onmaintaining high fidelity response preven-tion. Anxiety is in no short supply thesedays; thus, fear structures are activatedacross the board. Even in the event that apatient does not have pronouncedCOVID-19-related distress (indeed, thereis not yet evidence to suggest that an indi-vidual with OCD has more virus-relatedfear than the general population), simplyinteracting with the world in a manner thatis free of rituals will likely bring about

CLINICAL PRACTICE FORUM

Adapting Exposure and Response Preventionin the Age of COVID-19Jason W. Krompinger, Jennie M. Kuckertz, Meghan Schreck,Jacob A. Nota, Nathaniel Van Kirk, Martha J. Falkenstein,McLean Hospital/Harvard Medical School

June • 2020 167

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“therapeutic” levels of anxiety. Thus, natu-ralistic exposures abound. Patients can stillwork on reducing frequency of hand-washes, length of showers, and eliminatingavoidances. The CDC has laid out clearguidelines for minimizing risk of infectionthat include handwashing for 20 seconds,avoiding touching one’s face, sneezinginside of one’s elbow or into a tissue, anddisinfecting frequently used surfaces. Apatient should be encouraged to notice theways that OCD “wants more” insofar as itwill pull for an exaggeration of these guide-lines to the point where it is functionallyimpairing. For example, a patient maythink “if 20 seconds is recommended, 40seconds must be even better.” Efforts toresist touching one’s face may result inavoidances of brushing one’s hair or teethor bringing a cup to one’s mouth to drink.Patients may take a “surgical hands”approach following a handwash, makingcareful efforts to avoid contact with items

in their living space for as long as possiblebetween handwashes. Disinfecting surfacescan become a multitiered, exhaustive,hours-long production. Clinicians shouldencourage patients to adhere to the guide-lines and to go no further. Patients shouldbe encouraged to expect, and indeed invite,the experience of lingering anxiety and“not just right” experiences following thecompletion of a CDC-approved handwashor disinfecting procedure. Helping patientsto adhere to CDC guidelines withoutmoving beyond them can constitute anexposure in and of itself, and can serve as auseful exercise in self-assessment so as tounderstand the underlying processes thatmaintain OCD.

Be Creatively Precise With ExposuresThe heterogeneity of OCD extends both

across and within symptom-based cate-gories. While it is reasonable to think that

treating contamination OCD is theapproach most affected by the pandemic, itis important not to make such assumptionsand abandon functional analysis. Thepublic health crisis does not directly impactall symptom presentations of contamina-tion OCD. For many presentations, expo-sure will require little to no adaptation inthe era of COVID-19. For patients withcontamination OCD, it is especially impor-tant to get specific about the underlyingcore motivation of OC symptoms and thefunction of rituals. By doing so, it is likelythat even a high percentage of contamina-tion OCD exposures can proceed effec-tively. In some cases, there may be evenmore opportunities than usual for appro-priate exposure.

For example, patients who fear beingpoisoned from household chemicals willhave more chances to practice exposure astheir use is increasingly encouraged, andpatients who fear vomiting from slightly

a d a p t i n g e r p i n t h e a g e o f c o v i d - 1 9


k r o m p i n g e r e t a l .

expired food may have more reason topush their boundaries in this domain asnonessential grocery trips are discouraged.For patients whose contamination or harmobsessions are quite specific to COVID-19,situational exposures will need to beadapted and alternative methods of expo-sures can be used to expose patients to theircore fear. For example, imaginal exposurescripts about contracting the virus orspreading it to others may be helpful.Imaginal exposures are particularly helpfulfor individuals who fear that simply havingthe thoughts increases the likelihood ofharm (thought action fusion; Shafran et al.,1996), with feared outcomes that cannot betested (e.g., Will I go to hell?), and/or fear acatastrophic event coming true (e.g., dyingor causing death due to COVID-19). Withan imaginal exposure, an individual canallow themselves “to go there” with theworst-case scenario, in turn, giving theirthoughts about the possibility of this out-come less power.

moreover, in the time of COVID-19,there may be a subset of patients who feellike they have permission to engage in theirrituals and/or avoidance. This certainlyapplies to compulsions functioning to pre-vent the spread of contamination (e.g.,washing), but may also extend to comorbidconditions of social anxiety wherebypatients feel relief to stay home and “socialdistance” themselves. A maladaptivebehavior (i.e., washing hands, staying athome) now becomes adaptive. However, itis important for patients, who are generallymotivated to engage in these behaviors outof fear, to continue to push themselves out-side of their comfort zone. For someonewith washing compulsions who now feelssafe after washing for 20 seconds, theycould retrigger their fear after washing byintentionally bringing on the thought, “It’spossible that I could still contract corona-virus.” For individuals who avoid social sit-uations due to anxiety, they can initiate andparticipate in video chats.

Function Over Form—Two Functions Versus One

Some individuals have made the obser-vation that, given the CDC guidelinesaround handwashing, disinfecting, andsocial distancing, it can appear that “every-one has OCD.” This, of course, is not actu-ally the case. While vast swaths of the pop-ulation make efforts collectively to “flattenthe curve,” their experiences while doing soare likely qualitatively different than thosewho actually struggle with obsessions and

corresponding compulsive behavior. Whatis this difference?

It reduces to a core function of thebehaviors in question. Imagine two peoplein a bathroom approaching the sinks towash their hands. One has OCD, and theother does not. The person without OCD iswashing their hands primarily to accom-plish a single goal: to adhere to social andmedical guidelines around personalhygiene. The person with OCD is washingtheir hands to accomplish multiple goals:while ostensibly they are also attempting tofollow the given guidelines, they are at thesame time attempting to control their innerexperience (i.e., reduce anxiety, disgust, or“not just right” experiences) and eliminateuncertainty. This can manifest as excessivethoroughness, repeating behaviors, rigidityaround the handwashing procedure, andan inability to end the handwash until aparticular emotional state is achieved.

In treating OCD, emphasis should beplaced on this core distinction, particularlyin the age of COVID-19. Patients should beinvited to notice the intention behind theirbehaviors when navigating the world.Indeed, the reality is that we need to washour hands frequently to minimize risk ofinfection. The reality is also that there is alevel of anxiety that goes along with thisand other recommended behaviors irre-spective of clinical diagnosis—manypeople are beginning to experience somelevel of emotional discomfort that existsbetween the moment they return from thegrocery store to the moment they are ableto access the hand sanitizer. However,there is a difference between washinghands to follow a guideline and washinghands as a means of eliminating all per-ceived possibility of infection. The guide-lines are not intended to be emotion regu-lation strategies. No matter how muchnews we consume or statistics we track,there is nothing on the internet that will tellyou, definitively, whether you will die fromCOVID-19. Further, there is a level of anx-iety and uncertainty that will persist irre-spective of the amount of wipes we use orhow carefully we socially distance.

Whether or not someone struggles withsymptoms of OCD (or any other anxiety-based disorder), we all contend with seedsof doubt or uncertainty around our safetyand the safety of those around us, and if weare doing “everything” we can to maintainthat safety to remain functional amid thisnew normal. It is necessary to accept thisuncertainty in order to move forward andparticipate in daily activities. Thus, if theimpetus behind our behaviors is to make

reasonable efforts to stay safe (akin tobuckling a safety belt) rather than eliminateall discomfort, risk, and doubt in an effortto gain 100% certainty, we protect againstour behaviors from becoming ritualisticand therein interfering with treatmentmechanisms (cf. Thwaites & Freeston,2005).

Address Context and RelationshipWith Anxiety and Uncertainty

In the context of this pandemic, we feelthat it is important that the rationale fortreatment is discussed in a manner that fitsbest with the realities of the situation whileremaining consistent with the evidencebase. Although ERP has been considered agold-standard intervention for OCD fornearly four decades, there is ongoing dis-cussion around the mechanisms of action.

Two major approaches include theseminal emotion processing theory (EPT;Foa & Kozak, 1986) versus the more recentinhibitory learning theory (ILT; Craske etal., 2008). Conducting ERP based on tradi-tional EPT tends to focus on habituation,such that patients are tasked with complet-ing exposures via a fear hierarchy and onlymoving up the list when the anxiety sub-sides. Ostensibly, patients learn that anxi-ety is transient and that rituals are unneces-sary as a means of controlling distress orpreventing disaster. Given the equivocaldata around the utility of habituation as apredictor of treatment outcome (Craske etal.), the ILT model deemphasizes habitua-tion and instead posits that expectancy vio-lation is the critical mechanism. Under theILT model, patients complete exposures asa means of building distress tolerance,placing them in a position to learn thatanxiety can be withstood in the face of mul-tiple different triggers across a variety ofcontexts. This violates the patient’s threat-associations with their obsessional content,and helps to develop and access new“inhibitory” or safety associations. Therespective emphases of these models maylead OCD clinicians to frame ERP a bit dif-ferently, depending on their own trainingand other idiosyncratic experiences.

Given the consistent and steadily risinganxiety across the world at this time, therationale for ERP should center aroundaddressing the patient’s relationship withanxiety and uncertainty. Habituation canbe a tough sell in the current environment.Propping up ERP as a means of eliminatinganxiety (via habituation) may inadver-tently reinforce the notion that anxiety issomething that needs to be eliminated.

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This is problematic even in the absence ofthe current crisis, but overemphasizinghabituation at this time runs the risk ofpathologizing that which is perhaps notpathological. Developing a healthy coexis-tence with distress via acceptance of itspresence is a reasonable alternative.

Clinicians may run into similar prob-lems if they push the idea that exposure is ameans to learn that feared consequencesare unlikely. Our knowledge around whatactually is likely or not likely appears tochange by the day, and an overemphasis ontaking solace in low probabilities can inter-fere with a patient's efforts to sit with theirdistress. Placing renewed emphasis on tol-erating uncertainty fits better with theseuncertain times.

Taken together, acceptance of distressand tolerance of uncertainty constitute acultivation of flexibility—a patient isencouraged to develop a richer behavioralrepertoire in the face of difficult innerexperiences. Common third-wave ERPaugments, such as acceptance and commit-ment therapy (ACT) and dialectical behav-ior therapy (DBT), provide useful languageand approaches in helping patients tounderstand acceptance and develop lessantagonistic relationships with distress anduncertainty. For example, an exposure car-ried out from an ACT framework mayemphasize engaging in value-drivenbehavior amidst intrusive thoughts (e.g., apatient might write out thoughts aboutharm coming to family members on piecesof paper and then post them on the walls oftheir apartment before initiating a Face-Time conversation with their family)whereas the traditional ERP approach maybe structured such that an intrusivethought is read repeatedly until the patientexperiences a decrease in their distress.

Expand Definitionof Ritualistic Behavior

Ritualistic handwashing, cleaning, dis-infecting, checking, and avoiding are fairlyeasy for clinicians and patients to spot, asare mental rituals such as neutralizing andreviewing. In the context of COVID-19, itis prudent for patients to expand the defin-ition of rituals and avoidances. For exam-ple, it is difficult to classify a patient whofears public transportation and publicrestrooms as “avoidant” in the current cli-mate. However, there are other behaviorsindividuals struggling with OCD symp-toms may engage in that serve as importanttargets for treatment.

Repetitive negative thinking (RNT),such as rumination and worry, can be par-ticularly prevalent during such times ofsocial isolation and lack of structure.Although they likely serve to perpetuatedistress, engagement in these processesserves a function. Worry, for example, ishistorically thought to serve as experientialavoidance of distressing imagery. morerecent accounts posit that engaging inworry may serve as a “contrast avoidance,”i.e., perpetuating a negative mood state soas to prevent being emotionally blindsidedby a catastrophic event (Newman et al.,2011). For example, persistently worryingabout harm coming to a family member isa way of avoiding the unpleasant experi-ence of a rapid “shift” from positive/neutral(in the event that worrying was not occur-ring) to negative emotional state thatwould be brought on by receiving a phonecall that said family member has fallen ill.

Engagement in RNT can be accompa-nied by behaviors that set the occasion forcontinued RNT—individuals may avoidwatching a funny show, having a virtualget-together with friends, engaging in exer-cise, or interacting with loved ones becausethey are “too anxious.” On the other end ofthe spectrum, it is easy to avoid potentiallyuncomfortable tasks and turn to immedi-ately gratifying behaviors. This can resultin disrupted sleep schedules, neglect of per-sonal hygiene and physical health, alcoholand substance use, arguments with signifi-cant others, etc. While these behaviorstechnically fall outside the scope of OCD,they can all be conceptualized as a means toavoid an unwanted inner experience. This,of course, runs counter to the very crux ofERP. Clinicians would do well to monitorsuch behaviors and invite them to considerit part of their OCD treatment to keepthem in check. Framing RNT and accom-panying avoidant behaviors as just as insid-ious and deleterious as “standard” OCDrituals can help patients understand theinsidious nature of the disorder and maketheir self-monitoring approaches morenuanced.

It may be useful to patients to expandthe definition of rituals and avoidances toinclude all types of emotion-driven behav-ior. For example, as the COVID-19 pan-demic unfolded it was important to stay upto date with current information and rec-ommendations. However, as anxiety inresponse to current information increases,the desire to “gather more information”may increase—following the same slipperyslope as the more overt rituals describedabove. These behaviors may increase even

more after reading sensationalized head-lines. Thus, it is important to balance stay-ing up to date with not using informationgathering as a method for avoiding uncer-tainty. Limiting news consumption andfocusing on getting updates from reputablesources (such as the CDC) in a planful wayis important. It may be that a clinician dis-cusses only getting news updates once perday while inviting a patient to considerwatching goofy videos on YouTube insteadof reading yet another coronavirus-relatedarticle as an exposure to sit with the uncer-tainty of not knowing the most recentheadlines. The CBT framework provides amultitude of tools for addressing RNT,including applying mindfulness, defusion,“worry time,” and problem solving.

Leveraging TelehealthWhile tele-ERP was gaining a good deal

of traction long before COVID-19, we sud-denly all find ourselves thrust into provid-ing this service. many clinicians bemoanthis change, given the sense that there areelements of in-person therapy that simplycannot be re-created when the clinicianand patient are relegated to faces in boxeson screens. However, telehealth can serveas a boon to ERP practitioners. An individ-ual’s triggers can often be found in thehome, irrespective of specific symptomsubtype. This can provide extensive oppor-tunities for tele-ERP coaching. Theremight be emotionally contaminated itemsto touch, stoves and windows to leaveunchecked, Bibles to defile, school papersto write imperfectly, or family photos ofindividuals to wish harm upon. A therapistmay task a patient with posting triggeringimages or thoughts on pieces of paperaround their living space. Because the tele-therapy applications are usable on portabledevices like smartphones, a clinician couldcoach a patient through handwashes orother activities of daily living by having thepatient “bring them into” the bathroomand perch the device on a countertop.

In Craske and colleague’s (2014) semi-nal paper on how to apply inhibitory learn-ing to maximize exposure therapy, theauthors outline “multiple contexts” as animportant therapeutic strategy. Access tomultiple contexts via telehealth may pre-vent context renewal. Context renewalinvolves the return of fear to a trigger in anenvironment that is different from whichexposure therapy was conducted (e.g.,mineka et al., 1999). Conducting exposureand response prevention in multiple con-texts might offset context renewal in


k r o m p i n g e r e t a l .

patients with OCD, given these findings inhuman laboratory studies (e.g., Balooch &Neumann, 2011) and in a clinical analogstudy of exposure therapy (Vansteenwegenet al., 2007). Physical distancing has pre-vented clinicians and patients from com-pleting in vivo exposures in a variety ofcontexts. However, telehealth allowspatients to access “home visits” such thatbehavior therapists can coach patientsthrough exposures in their own home, asmentioned above. Additionally, whileCOVID-19 prevents some in vivo expo-sures, this may be a time to prioritize inter-nal contexts, such as a patient’s physiologi-cal and cognitive state by practicinginteroceptive and imaginal exposures,respectively (Craske et al., 2014). For exam-ple, a patient might be coached to practiceboth willingly bringing in an intrusiveimage about acting on impulses to harmothers in public while at the same timeallowing for resultant physiological sensa-tions such as rapid heartbeats, muscle ten-sion, and physiological arousal.

Finally, being brought into the homealso affords the therapist an opportunity toclosely assess the patient’s physical envi-ronment and make suggestions so as toreduce its conduciveness to ritualizing.Therapists might encourage patients tocover or remove mirrors to reduce check-ing behaviors in patients with body dys-morphic disorder or body-focused repeti-tive behaviors (e.g., trichotillomania,excoriation disorders), rearrange furnitureto make it less likely that a patient sits in thechair in which they typically mentallyreview, or posttreatment-related cues ontheir fridge to remind them to resist ritualswhen preparing food. Through screen-sharing functions, therapists can coachpatients through writing or reading exer-cises, view images, or watch videos. We arein as good a position as we have ever beento deliver ERP to our patients remotely,given the flexibility of the software andubiquity of the hardware.

Considering the Impact on TreatersFor some treaters this may be a unique

time where the distance between their ownanxiety and uncertainty and that experi-enced by the people they serve is closerthan ever (or even overlapped). As isalways the case, but is even clearer now, weare attempting to enact the principles thatwe share with those we serve in our ownlives. It is important for us to investigate thefunctions of our own behaviors in responseto coronavirus. For our ongoing interac-

tions with those we serve, maintaining orinitiating professional consultations maybe important. Having regular check-inswith loved ones and discussing the ways weare coping and supporting each other canalso support our work in addition to our-selves. It is prudent for treaters to stayinformed about the current recommenda-tions for “flattening the curve,” but we arealso vulnerable to perseverating on pan-demic-related news. Professional agencies,including ABCT, have been rapidly releas-ing helpful resources (e.g., Weir, 2020).Gathering information in a limited androutine fashion from trusted sources (e.g.,CDC, World Health Organization) hasbeen widely recommended. Indeed, thereis some evidence that gathering informa-tion from traditional news sources (news-papers and broadcast news) rather thansocial media is associated with less fear andmore engagement with effective protectivebehaviors in response to emerging healththreats (Chan et al., 2018).

Routine and intentionality are alsoimportant for treaters to maintain theireffectiveness. Regularizing one’s sleepschedule by focusing on keeping wakingtimes consistent (i.e., arising within 1 hourof the same time each day, regardless ofexternal demands on one’s schedule) canhelp maintain circadian rhythms, whichwill benefit the quality of nighttime sleep aswell as daytime mood and functioning(monk et al., 2003; Walker, Walton,DeVries, & Nelson, 2020). Light daily exer-cise and diet are also valuable. Takingopportunities to engage in pleasurable andpresent-moment-focused activities andexperiences (e.g., listening to music, eatinga favorite snack, watching a funny TVshow) are not a “waste” of time but impor-tant behavioral activation maintenancefactors. Perhaps most important, contin-ued engagement with one’s values andvalued action is expected to distinguishthose who cope well with this uncertainand anxious time. Taking time to pauseand take stock of what matters to you andthen identifying realistic and meaningfulgoals for the short- and longer-term hasbeen suggested as a viable intervention forindividuals facing the stress of serious ill-ness (Folkman & Greer, 2000). Appropri-ately for times like these, Folkman andGreer suggest that what might be mostimportant is a focus on opportunities forpersonal control over actions that alignwith one’s values. Thankfully, for manytreaters, providing care to others is animportant value and engaging in our workwith those we serve may be nourishing and

protective to our psychological functioningduring this time. Finally, practicing flexi-bility in response to the rapidly changingprofessional and personal landscape is anecessity. many treaters develop systems tomanage their time and these may beupended. It is invaluable for treaters to givethemselves compassion and accept thatpandemic will have an impact on them aswell.

ConclusionThe intention of this article was to offer

some core constructs to reflect upon whenconsidering adjustments to the implemen-tation of ERP amidst the current pandemic.Although we do not yet have data that pro-vides evidence for the efficacy of theseadjustments under these circumstances, weconsidered the state of the science inmaking these suggestions, and considerthem highly likely to preserve treatmentintegrity. The COVID-19 crisis is perhapsirrevocably changing the way that we liveour lives. The OCD treatment communitydoes a service to its patients by modelingflexible adaptation to the circumstances.

ReferencesBalooch, S. B., & Neumann, D. L. (2011).

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Foa, E., Huppert, J., & Cahil S (2006).Emotion Processing Theory: An Update.In B. O. Rothbaum (Ed.), Pathologicalanxiety: Emotional processing in etiology

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mineka, S., mystkowski, J. L., Hladek, D.,& Rodriguez, B. I. (1999). The effects ofchanging contexts on return of fear fol-lowing exposure therapy for spider fear.Journal of Consulting and Clinical Psy-chology, 67(4), 599.

monk, T. H., Reynolds III, C. F., Buysse,D. J., DeGrazia, J. m., & Kupfer, D. J.(2003). The relationship between lifestyleregularity and subjective sleep quality.Chronobiology International, 20(1), 97-107.

Newman, m. G., & Llera, S. J. (2011). Anovel theory of experiential avoidance ingeneralized anxiety disorder: A review

and synthesis of research supporting acontrast avoidance model of worry. Clin-ical Psychology Review, 31(3), 371-382

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Vansteenwegen, D., Vervliet, B., Iberico,C., Baeyens, F., Van den Bergh, O., &Hermans, D. (2007). The repeated con-frontation with videotapes of spiders inmultiple contexts attenuates renewal offear in spider-anxious students. Behav-

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Weir, K. (2020, march 16). Seven crucialresearch findings that can help peopledeal with COVID-19. The American Psy-chological Association News. Retrievedfrom https://www.apa.org/news/apa/2020/03/covid-19-research-findings

. . .

No conflicts of interest or fundingto disclose.Correspondence to Jason W. Krompinger,Ph.D., mcLean OCDI Office of ClinicalAssessment and Research, 115 mill Street,mail Stop #207, Belmont, mA 02478;[email protected]

THE RAPID SPREAD of the novel coron-avirus (COVID-19) in the past severalmonths has created unprecedented chal-lenges across multiple domains of life. Inan attempt to slow the spread of the virusand minimize the dangers associated withoverburdening health care systems,authorities across the United States haveimplemented physical distancing mea-sures, asking people to stay at home andavoid nonessential travel and outings. Inorder to continue providing services whileadhering to physical distancing measures,many mental health care providers havetransitioned to providing therapy via tele-health technology, but are unsure of how toadapt procedures and materials. In particu-lar, youth-focused providers may be uncer-

tain how to shift therapy online while keep-ing children and adolescents activelyengaged during sessions.

We aim to provide guidance to youth-focused practitioners who are consideringtransitioning therapy services to a tele-health format. We have developed theserecommendations based on our experienceproviding home- and school-based tele-mental health services, as well as trainingpredoctoral clinical psychology interns todo so through the Telehealth OutreachProgram (TOP) within the mental HealthDisparities and Diversity Program at themedical University of South Carolina(mUSC). Although TOP was not formallyestablished until 2015, practitioners frommUSC have been delivering evidence-

based mental health treatments to under-served children and adolescents throughtelehealth technology since 2011 (see Joneset al., 2014, and Stewart, Orengo-Aguayo,Gilmore, et al., 2017, for more detail).

A Brief Overviewof Telemental Health

Telemental health refers to the use ofinteractive real-time technologies (e.g.,videoconferencing) to deliver mentalhealth care to clients (Centers for medicareand medicaid Services, 2020). Use of tele-health technology can extend the reach ofevidence-based care and address healthdisparities by minimizing logistical barriersto help-seeking (e.g., distance from theclinic, lack of transportation or childcare;myers & Comer, 2016; Yellowlees et al.,2008). Within the last decade, there hasbeen an exponential increase in empiricalstudies investigating the effectiveness oftelemental health interventions, whichhave been proven to be effective at treatingvarious disorders, including depression,anxiety, posttraumatic stress disorder(PTSD), and substance use disorders (Hiltyet al., 2013). Additionally, research hasshown that telemental health is an effectivetreatment modality for both adults andchildren (Gloff et al., 2015; Hilty et al.), andacross diverse racial and ethnic groups(Hilty et al.). Furthermore, research sug-gests telemental health interventions maybe as effective as in-person treatment andyouth and their caregivers report high sat-

CLINICAL PRACTICE FORUM

Resources and Recommendations for EngagingChildren and Adolescents in Telemental HealthInterventions During COVID-19 and BeyondAubrey R. Dueweke, Megan M. Wallace, Andel V. Nicasio,Medical University of South Carolina

Bianca T. Villalobos and Juventino Hernandez Rodriguez,University of Texas Rio Grande Valley

Regan W. Stewart, Medical University of South Carolina


d u e w e k e e t a l .

isfaction with telemental health services(Bashshur et al., 2016; Stewart, Orengo-Aguayo, Cohen, et al., 2017). Children andadolescents in particular seem to enjoytelemental health services, perhaps becauseof their status as “digital natives,” havinggrown up with technology present for all oftheir lives (Alvord, 2020; myers et al.,2017). Although no specific theoretical ori-entation has been contraindicated fordelivery via telehealth technology, cogni-tive behavioral approaches are the mostcommonly studied in the literature and arewell-suited to the telehealth format due totheir structure and skill-building focus(Nelson & Duncan, 2015).

Providers contemplating offering tele-health services can find many guidelinesregarding programmatic and logisticalconsiderations in the extant literature. Forinstance, the American TelemedicineAssociation (myers et al., 2017), the Amer-ican Psychiatric Association (Shore et al.,2018), the American Psychological Associ-ation (American Psychological Associa-tion, 2013), and the American Academy ofChild and Adolescent Psychiatry (Ameri-can Academy of Child and Adolescent Psy-chiatry, 2017; myers & Cain, 2008) have allcreated practice guidelines to assistproviders in establishing videoconferenc-ing-based telemental health services. Ingeneral, providers first need to familiarizethemselves with local, state, and federalregulations related to delivering carethrough videoconferencing (e.g., billing,licensure requirements, confidentiality,consent, mandated reporting guidelines).Next, providers need to ensure they havethe appropriate equipment and softwarefor telemental health service delivery. At aminimum, providers should have access toa computer or laptop with a webcam and areliable internet connection, with sufficientbandwidth to detect accurate visual, audi-tory, and interactional cues from clients.Though not required, it is also recom-mended that providers have a headset witha microphone, dual monitors, and a soundmachine, if available. Additionally,providers need access to software that com-plies with Health Insurance Portability andAccountability Act (HIPAA) specificationsand has screen sharing capabilities. Ofnote, the U.S. Department of Health andHuman Services has temporarily relaxedHIPAA requirements for the duration ofthe COVID-19 national emergency (Officefor Civil Rights, 2020). In order to receivetelehealth services, clients need to haveaccess to a computer, tablet, or smartphone

with a reliable internet connection, andheadphones are recommended, if possible.

While there is widespread availability ofinformation about programmatic andlogistical considerations for telehealth ser-vice delivery, there are fewer guidelinespertaining to adaptations to therapy deliv-ery itself. Generally, experts advise thatpractitioners working with children andadolescents via telehealth need to be moredynamic and interactive than they wouldbe during in-person visits and shoulddeliberately amplify their animationduring sessions to keep clients engaged(myers & Cain, 2008). Recently, Seager vanDyk and colleagues (2020) put forth a set ofrecommendations for how this might lookin practice. For example, they recommendusing exaggerated facial expressions andhand gestures such as virtual high fives,increasing use of summary statements tomake it clear to clients that providers arelistening, and seeking more verbal confir-mations of mutual understanding (Seagervan Dyk et al.). Jones and colleagues (2014)also underscore the importance of beinginteractive, suggesting that providers caneither mail handouts and session materialsto youth and their caregivers ahead of time,or share and alter documents in real timethrough the use of their videoconferencingsoftware’s screen sharing function. How-ever, applied examples and explanations ofactual telehealth resources practitionerscan use in clinical practice with childrenand adolescents are scant.

PurposeGiven the heightened need for mental

health providers to transition their cases toa telehealth format in the midst of COVID-19 and the relative scarcity of guidelinesand resources for telehealth service deliv-ery with children and adolescents specifi-cally, we aim to put forth a set of recom-mendations informed by our experiencedelivering an evidence-based treatment(Trauma-Focused Cognitive BehavioralTherapy; TF-CBT) via telehealth to chil-dren and adolescents. In addition to outlin-ing specific recommendations for settingup telehealth services with youth andmaking adaptations to therapy, we alsoillustrate how these recommendationscould look in practice and describeresources we have created for telementalhealth service delivery with children andadolescents (freely available at www.tele-healthfortrauma.com). While the resourcesdescribed were developed within the con-text of a trauma-focused service setting,they are broadly applicable across cognitive

behavioral interventions for a range of dis-orders.

RecommendationsRecommendations for Setting UpTelehealth Services for Youth• Recommendation #1: Orient clients to tele-health services and obtain consent. In themidst of the COVID-19 emergency, manyproviders and youth who were previouslyengaged in office-based treatment have hadto abruptly transition to telehealth becauseof new physical distancing requirements.This brings up unique issues regardinginformed consent. We recommend thatproviders transitioning their existing case-loads to telehealth orient their clients to therisks and benefits of telehealth services,inform them that they have the right todecline telehealth services at any time, andprovide an overview of how the transitionmay impact billing and insurance coverage.Providers should also consult with theirinstitution and state licensing boardregarding requirements for procuringinformed consent for telehealth services.Various options for acquiring informedconsent for telehealth treatment during theCOVID-19 emergency include obtainingverbal consent with a witness, sending aconsent form electronically, or mailing aphysical copy of a consent form to thefamily and asking them to sign and returnit.• Recommendation #2: Model proper use oftelehealth equipment. Depending on theage of the client, providers may need todemonstrate proper use of telehealthequipment with youth and their caregivers.Although they may have previous experi-ence with technology and be comfortablewith video chatting, clients may be unfa-miliar with the functions of a specific tele-health platform. Providers should alsoshow clients how to position their chair ordevice to keep their full face in view of thewebcam. While adolescents will likelyunderstand proper telehealth “etiquette”with little explanation, younger childrenmay require additional review and practiceacross several sessions.• Recommendation #3: Discuss expectationsfor therapy sessions. Expectations regardingproper attire, body position in front of thewebcam, scheduling, and removing dis-tractions (e.g., television off, silencingphones) should be discussed with bothcaregivers and youth. Setting clear expecta-tions from the outset can help familiesadjust to the new therapeutic setting and


decrease time spent troubleshooting theseissues during subsequent sessions.• Recommendation #4: Identify a privatelocation for telehealth services. Sessionsshould be held in a location that allows theyouth to have some privacy. We recom-mend youth find a location with a chair ortable where the telehealth device can besupported, giving youth the freedom tomove and engage in physical activities. Ithas been our experience that youth oftenchoose to use their bedrooms for home-based sessions. Although this is acceptable,we recommend youth not sit on their bed ifpossible, as the surface may be unstable andlimit mobility. However, if this is the onlysurface available, boundaries should be putin place (e.g., youth should be dressed,should not be under covers during ses-sion). Youth should be in a private locationfor sessions; however, it is important thatcaregivers are still able to gain access to theyouth in the case of an emergency (i.e.,youth should not be in a room with alocked door). We recommend providershold this discussion at the outset of therapywith both the youth and caregiver present.Together they can determine the ideal loca-tion for sessions and agree upon allowingthe youth private time without disruptionsfrom family members or friends. Privacycan also be enhanced with the use of head-phones, a code word to indicate that some-one has entered the room, and the youth“giving the clinician a tour” of the spacewhere the session will occur.• Recommendation #5: Develop an emer-gency protocol with the caregiver(s) andyouth. When conducting home-based tele-health sessions, it is recommended that acaregiver always be present in the homeand reachable by phone for the entire dura-tion of the youth’s session. From our expe-rience, caregivers often trust their child toinitiate sessions on their own and assumethat the caregiver can arrive at the homelater for their own time with the provider.While it may be true that youth, and olderadolescents in particular, are capable of ini-tiating sessions on their own, an adultshould still be accessible, regardless of theyouth’s age. It is also important for the clin-ician to develop a protocol for what willhappen in the case of an emergency (e.g., ifthe child says they want to harm them-selves or if the child leaves the view of thewebcam unexpectedly). This protocolshould be explained to the youth and care-giver at the outset of treatment. For school-based telehealth sessions, providers shouldbe familiar with and adhere to the school’s

existing emergency protocol, and a schoolstaff member should be available to theprovider by phone to assist in the event ofan emergency.• Recommendation #6: Establish a routineto transition into and out of therapy ses-sions. We recommend providers orientfamilies to telehealth sessions by establish-ing a “starting routine” that includes turn-ing off devices (e.g., televisions, radios),silencing phones, getting comfortable attheir therapy chair, and initiating the tele-health session. In similar fashion, cliniciansare encouraged to assist families in estab-lishing an “ending routine,” which includesa pleasurable activity at the end of sessionbetween the youth and provider (e.g.,board game, relaxation exercise, drawing)and/or an activity for the youth and care-giver to do together in order to facilitate aneasier transition back to everyday activitiesafter the therapy session.

Recommendations for Adaptationsto Therapy Delivery• Recommendation #7: Use interactiveactivities. Similar to in-person psychother-apy, telehealth sessions should be interac-tive and engaging in order to build rapportand keep the child actively engaged in thetherapy sessions. Telehealth allows theprovider to use online interactive tools,which are attractive and enjoyable to chil-dren, as well as traditional psychotherapytools, such as feelings cards and books, toaccomplish this. For example, we have cre-ated a number of interactive games usingmicrosoft PowerPoint that providers canuse during the initial phase of treatment tobuild rapport and deliver psychoeducation(see Therapy Trivia on www.telehealthfor-

trauma.com, Figure 1). In addition to help-ing the child grow comfortable with theprovider and the telehealth format, thesegames also allow for the provider to beginassessing the child’s knowledge of thera-peutic themes such as safety, family sup-port, and coping skills.• Recommendation #8: Take frequentbreaks to keep children engaged. Unlike in-person services, telehealth delivery of ser-vices may involve distractions within theyouth’s home environment (e.g., toys in thebedroom, family activities overheard froman adjacent room). Additionally, duringthe current COVID-19 emergency, manychildren are being asked to focus attentionon a screen throughout the day for distanceschoolwork, social connection with familyand friends, and now, for therapy. Giventhis context, it is particularly importantthat providers are aware of the need forsmall breaks throughout session toenhance children’s ability to focus andengage for longer periods of time. manyresources are available online to facilitatethese activity breaks, including free or low-cost books, Excel or PowerPoint games, orvideos uploaded to YouTube. Youngerchildren will likely need more breaks thanadolescents, and the types of activities usedduring breaks may differ depending on thechild’s age.• Recommendation #9: Utilize physicalthings in the child’s environment. Creating atherapeutic setting in a home-based envi-ronment can often be challenging to thera-pists. Even with thorough assessment andclear guidelines for families, distractionsmay still occur, as children readily haveaccess to toys and other objects that maypull their attention away from therapy.

Figure 1. Sample interactive PowerPoint games. For a full explanationof the purpose of these games, as well as instructions for their use intherapy, visit www.telehealthfortrauma.com

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d u e w e k e e t a l .


This is where creativity can come into playand a provider can use the environment totheir advantage. For example, a provider inour program was working with an 8-year-old girl who was often very distracted by atoy doll during session. Rather than askingthat the doll be put away during session, theprovider asked the child if the doll wouldlike to participate and answer questions.The child then utilized the doll to respondto questions and activities throughout thesession, which resulted in an increase inengagement.

Often when providers transition to tele-health delivery of services, they defer toonly using electronic documents duringsession. However, providers can also mailitems (e.g., stress balls, mindfulness cards,bubbles, markers and paper, fidget toys) tothe home or school so that the child canphysically manipulate objects during ses-sions. While this requires a provider toplan ahead for what may be needed, itallows them to venture beyond simplyusing screen sharing to facilitate interactiveactivities in session.• Recommendation #10: Tailor activities toeach child’s interests to enhance engage-ment. While the use of interactive gamesand other engagement strategies usuallyhelps foster children’s sustained attention,some youth may require additional effortson the part of the therapist to get them to“buy in” to certain therapeutic activities.For example, one resource our team cre-ated (see Relaxation: Breathing and Soccer

on www.telehealthfortrauma.com) wasdeveloped specifically for a 15-year-oldHispanic male who was hesitant to practicerelaxation skills and complained that someof the other activities the provider hademployed (e.g., diaphragmatic breathing)seemed “babyish.” However, the providerknew the youth played soccer and was anenthusiastic fan. As such, the cliniciandeveloped a PowerPoint presentation withimages explaining how important dia-phragmatic breathing is for soccer players’success. The tool also included images offamous soccer players from the teen’sfavorite Latin American team. Taking thetime to learn about the child’s interests andvalues, and incorporating this informationinto therapy, facilitates therapeutic rapportand shows clients that their therapist caresabout and respects them and their culturalbackground. We encourage providers totailor online resources as needed to makethem more suitable for their client popula-tion.• Recommendation #11: Adapt worksheetsand activities for digital use. CBT for youthis often interactive, involving the use ofworksheets and activities to introduce keyconcepts and increase engagement in thetherapeutic process. It has been our experi-ence that many CBT worksheets and activ-ities can be easily adapted for telehealth use(see Figure 2). For example, manyproviders use games like charades to teachyounger children how to identify emotionsand associated physiological responses

(e.g., clenching of fist when upset).Providers can create similar activities fortelehealth using microsoft PowerPoint andthen use the screen-sharing function oftheir telehealth platform to involve theyouth (see Feelings Charades on www.tele-healthfortrauma.com). For older childrenand adolescents, providers can create digi-tal versions of worksheets that can be com-pleted using mS Word (see CognitiveCoping Fill-In on www.telehealthfor-trauma.com). When adapting worksheetsand activities, it is important to considerthe age of the client. Younger children aretypically more engaged in session whenfrequent experiential exercises are incorpo-rated. Any written materials used withyounger children should have minimal text(displayed in large font) and medium-to-large images. For older children and ado-lescents, it may be useful to incorporate acombination of worksheets and experien-tial exercises.• Recommendation #12: Use technology toyour advantage. Historically, providersunfamiliar with telehealth have expressedworry about potential drawbacks of deliv-ering therapy through videoconferencing,while the unique advantages afforded bytelehealth are often overlooked. First, tele-health may allow providers to gain a betterunderstanding of the local social context inwhich their clients are living. For example,when discussing discipline issues in tradi-tional office-based settings, the provider isforced to imagine the home layout andpossible barriers that may interfere withintervention recommendations. Withvideoconferencing software, the providercan actually see the home setting and pro-vide more precise recommendations. Forinstance, when we teach time-out to fami-lies, we often ask to see the room wheretime-out will occur in order to practice andidentify possible distractions, which shouldincrease adherence and likelihood offollow-through in real-life scenarios.

Our team has also used technology toenhance in vivo exposures. Utilizing tech-nology to virtually accompany a childduring exposure activities can help withcompliance and problem solving in themoment. For example, one of our clini-cians was working with a medically com-promised youth who experienced signifi-cant anxiety symptoms in public settingsrelated to fears of being injured by fallingobjects crushing him. The child wasinstructed to take a tablet and headphoneswith him to stores and restaurants to com-plete exposures, with the therapist provid-

Figure 2. Sample CBT worksheets adapted for telehealth. For a full expla-nation of the purpose of these worksheets, as well as instructions for theiruse in therapy, visit www.telehealthfortrauma.com.

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ing live coaching remotely and ensuringexposures were completed appropriately.

many videoconferencing software plat-forms also include features that canenhance communication during the tele-health session. For instance, many plat-forms have chat features that can bolsterengagement with clients, particularly ado-lescents. Therapists can utilize the chat fea-ture to promote continued contact if anadolescent refuses to engage verbally, or toscaffold discussion of emotionally chargedtopics. Another useful feature available insome platforms is a white board or drawingtool. This allows the provider and child tointeract through the technology and con-tribute jointly to drawings, which can beparticularly useful when working withyounger children. Allowing the child todraw in session can help foster the thera-peutic alliance, increase cooperation, andcreate additional content to be utilizedthroughout session. Providers can thencopy and paste drawings into worksheetsor save them for later activities.

TroubleshootingA unique, and potentially frustrating,

characteristic of telehealth sessions is thepossibility of experiencing technical diffi-culties. With the increasing growth andexpansion of telehealth, videoconferencingplatforms have become more user friendlyand efficient, and are prone to fewer tech-nical issues than they once were. Neverthe-less, it is important for clinicians to famil-iarize themselves with the different featuresand capabilities of their chosen platformand be aware of the technical issues thatcould arise. For example, two of the mostcommon issues we have experienced areproblems with audio and video connectiv-ity. It is helpful for providers to have somebasic knowledge of the technology in orderto help youth and caregivers diagnose andfix problems. This knowledge can usuallybe acquired through completing test callsand reviewing frequently asked questionson the videoconference platform website.Providers may also consider creating trou-bleshooting guides that can be shared withfamilies at the outset of telehealth services.In addition, providers should investigatehow to get technical support if they are notable to resolve an issue directly (e.g.,through the videoconference platform helpdesk or through their own technologydepartment at their organization). It isimportant for clinicians to remember thatas they use the videoconference platformmore frequently, they will begin to feelmore confident in its use. Clinicians should

also be flexible and creative in the eventthat the technology may fail during a ses-sion. For example, we have resorted to theuse of telephone audio to supplement tele-health sessions when the client’s video isworking but their audio is not. As a lastresort, finishing a session over the tele-phone (without videoconferencing soft-ware) may be appropriate depending onthe age of the client and the planned ses-sion content.

DiscussionPractitioners working with children and

adolescents may need to make adjustmentswhen transitioning therapy services to atelehealth format, particularly in the con-text of COVID-19, which has created mas-sive disruptions to most youths’ daily rou-tines. In addition to taking sufficient timeto orient youths and their families to tele-health services and increasing use of inter-active activities during sessions, providersshould also allow space for conversationswith their clients about the myriad ways inwhich COVID-19 has impacted them.Although it may feel like a detour fromplanned session content, we encourageproviders to be flexible, as allowing time foryouths and their families to acclimate totelehealth services and process the impactof COVID-19 will likely contribute toincreased engagement in the long term.

We hope that the recommendationsoffered above, in conjunction with caseexamples and resources from our collectiveexperience, can provide guidance to practi-tioners who are feeling uncertain of how tomanage young clients while deliveringtherapy via videoconferencing software. Insum, being creative and flexible, and find-ing strategies to increase interaction andengagement of youth in telehealth sessions,is the key to success. While the resourcesand recommendations provided here weredeveloped within the context of a trauma-focused service setting, they are broadlyapplicable across cognitive behavioralinterventions for a range of disorders. Weencourage practitioners to use theseresources and suggestions as templates andtailor them to fit the needs of their ownprograms and services.

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Stewart, R. W., Orengo-Aguayo, R.,Gilmore, A. K., & de Arellano, m. (2017).Addressing barriers to care among His-panic youth: Telehealth delivery ofTrauma-Focused Cognitive-BehavioralTherapy (TF-CBT). the Behavior Thera-pist, 40, 112-118.

Yellowlees, P. m., marks, S. L., Hilty, D.m., & Shore, J. H. (2008). Using e-healthto enable culturally appropriate mental

health care in rural areas. TelemedicineJournal and E-Health, 14, 486-492.https://doi.org/10.1089/tmj.2007.0070

. . .

This work was supported by a SubstanceAbuse and mental Health Services Adminis-tration (SAmHSA) National Child Trau-matic Stress Network (NCTSN) grant,(1U79Sm063224). Content and conclusionsare those of the authors and should not beconstrued as the official position or policyof, nor should any endorsements be inferredby, SAmHSA, NCTSN, or the U.S. govern-ment. We have no known conflicts of inter-est to disclose.Correspondence to Aubrey R. Dueweke,Department of Psychiatry and BehavioralScience, 67 President Street, mSC 861, 4thFloor, IOP South, Charleston, SC [email protected]

Importance of DisseminationTHE FIELD OF PSYCHOLOGY has becomeincreasingly interested in disseminationand implementation science, as evidencedby dissemination and implementationbeing one of ABCT’s strategic initiatives(ABCT Board of Directors, 2018) and thecurrent petition to create a unique divisionof the American Psychological Associationdevoted to implementation science (Soci-ety for Implementation Research Collabo-ration: https://societyforimplementation-researchcollaboration.org/?page_id=2401.This focus is reasonable given the signifi-cant advances in understanding whichinterventions have empirical support foreffectively helping individuals with a vari-ety of mental health and behavioral con-cerns. For instance, the field has advancedto the point that the popular book A Guideto Treatments That Work, by Nathan andGorman (2015), is now in its fourth edi-tion.

Importance of Evidence-BasedParenting Interventions

One of the many forms of effectivetreatments the field of psychology has beenable to develop and evaluate is the treat-ment of dysfunctional parenting (e.g.,engaging in ineffective disciplinary prac-tices and failing to reinforce appropriatebehaviors) for the prevention and treat-ment of child behavior problems (e.g.,Eyberg & Child Study Lab, 1999; Forehand& Long, 2010; Kazdin, 2005; Sanders et al.,2001; Webster-Stratton, 2005). The reduc-tion of dysfunctional parenting, especiallydysfunctional discipline, has importantsocietal implications due to its correlationswith negative short- and long-term conse-quences. For instance, both mothers’ andfathers’ overreactive discipline is a signifi-cant unique predictor of the parent engag-ing in parent-to-child aggression (Slep &O’Leary, 2007) and corporal punishmenthas been associated with at least 11 detri-mental short- and long-term consequences

for the child receiving it, such as externaliz-ing problems in childhood and adult anti-social behavior (Gershoff & Grogan-Kaylor, 2016). Research has consistentlyshown that parent management interven-tions are effective at modifying parentingpractices (Sanders et al., 2014) and improv-ing important child outcomes, such asexternalizing behavior problems (minge-bach et al., 2018).

Difficulties With DisseminationDespite the availability of effective,

empirically backed parenting preventionand intervention programs, there are stilllarge percentages of the population unableto access and benefit from these programs(Committee on Supporting the Parents ofYoung Children, 2016). Two frequentmodalities for the programs are individualtherapy, such as that provided by Parentmanagement Training (Kazdin, 2005), andgroup treatment, such as that provided byThe Incredible Years Program (Webster-Stratton, 2005). Unfortunately, both ofthese modalities are necessarily limited—because of time and resource constraints—in how many individuals they can reach.An additional dissemination avenue hasbeen through the media. For instance,many effective programs have publisheduser-friendly books available for purchasein popular press formats (e.g., Forehand &Long, 2010) and other media tools such asapps, websites, blogs, and podcasts (e.g.,https://www.triplep-parenting.com/us/triple-p/). However, given the proliferation

ORIGINAL RESEARCH

Changes in College Students’ Opinions onParenting: Undergraduate Education asPrimary PreventionCarey Bernini Dowling, University of Mississippi

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c o l l e g e s t u d e n t s ’ o p i n i o n s o n p a r e n t i n g

of parenting advice available in these alter-native formats (as of February 5, 2020, aGoogle search for “parenting advice”yielded approximately 285,000,000results), it is easy for parents to becomeoverwhelmed by the amount of advice, andthus it is difficult to determine what iseffective. As such, it is important to con-tinue to explore potential avenues for dis-semination of empirically supported treat-ments, including parenting programs.Researchers have taken up this charge andare exploring the feasibility of dissemina-tion through multiple means, such as verybrief interventions (Tully & Hunt, 2016),electronic interventions (Breitenstein et al.,2019), and telehealth interventions (For-gatch & Kjøbli, 2016).

Despite the fact that prevention is typi-cally more cost-effective than intervention,the dissemination of prevention programsfor dysfunctional parenting may presentadditional challenges, and thus remains atop priority for future work on addressingmental health issues facing children andtheir families (Odar et al., 2013). mentalhealth services are underutilized for bothadults (Kessler et al., 2005) and youth, evenwhen the youth have significant sympto-matology (merikangas et al., 2011). It isthus not surprising that it is difficult tomotivate large groups of potential or cur-rent parents to engage in truly preventiveinterventions prior to any problems devel-oping (Ingoldsby, 2010). However, manyparenting researchers are employed inacademia with easy access to a large por-tion of the population given the fact thatthe rates of undergraduate enrollment haveincreased dramatically since 2000 and areprojected to continue to increase throughat least 2028 (National Center for Educa-tion Statistics, 2019). It is thus possible thatthe college classroom could serve as a rela-tively easy setting in which to expose largegroups of the population to the knowledgebase of empirically supported parentingstrategies, even if the students are not for-mally participating in an empirically sup-ported parenting prevention program.Fleming and Borrego (2019) presented evi-dence that undergraduate students’ atti-tudes towards the use of various disciplinebehaviors mediated the relationshipbetween the types of discipline theyreceived and the type of discipline theyintend to utilize, providing preliminarysupport that modifying students’ attitudesrelated to discipline may modify their laterparenting behaviors.

Present StudyThe purpose of the present study is to

determine if participation in a psychologyclass focused on parenting is an effectivemethod to modify students’ beliefs aboutideal parenting practices utilizing otherpsychology classes as a control group. Thispilot study is necessary to establish whetherit is possible to modify students’ beliefsprior to embarking on a more resource-intensive research program to determine ifundergraduate coursework in parentingcan truly be utilized as a primary preven-tion intervention. Given previous researchindicating dysfunctional discipline (e.g.,overreactive discipline and corporal pun-ishment) is an important predictor forboth short- and long-term undesired out-comes in children, this study focused onchanges in students’ support for overreac-tive discipline and corporal punishment inparticular. I hypothesized that studentsenrolled in the psychology class focused onparenting would reduce their endorsementof parents’ use of overreactive disciplineand corporal punishment behaviors asideal parenting behaviors from the start tothe end of the semester more than studentsin other psychology classes.

MethodParticipants

Undergraduate students enrolled in asenior-level undergraduate psychologyclass, Psychology of Parenting, and threejunior-level undergraduate psychologyclasses (Developmental, Learning, andSocial) were recruited in their classes toparticipate in this study. A total of 116 stu-dents consented and completed at leastsome portion of the pre- or postassess-ment. Forty-nine students were enrolled inthe Psychology of Parenting class, 38 inLearning, 18 in Developmental Psychol-ogy, and 11 in Social Psychology. Studentscould be enrolled in more than one class atthe same time. Due to the low number ofparticipants in Developmental and Social,two groups were created: parenting stu-dents and other students. If a student wasenrolled in the Psychology of Parentingclass, they were put in the parenting stu-dents group regardless of their enrollmentin other classes, with all other students inthe other students group.

Thirty-two students were removedfrom analyses: 23 other students (2 due tohaving taken the Psychology of Parentingclass in the past, 5 due to failure to com-plete the pre-assessment sufficiently toobtain scores, and 16 due to only complet-

ing the pre- or postassessment); 9 parent-ing students were removed due to onlycompleting the pre- or postassessment,resulting in a final sample of 84 students(40 parenting students). There were no sig-nificant differences on demographicsbetween students who completed bothassessments and those who did not.

The students analyzed were primarilyfemale (86.9%), Caucasian (61.9%) orBlack (34.5%), upperclassmen (98.8% weresophomores or above), and psychologymajors (65.5%). Four participants had atleast one child (all children were under theage of 5). Participants’ average age was20.63 (SD = 1.78). There were significantdifferences between groups on year inschool and age (the parenting studentswere further in sequence and thus older byapproximately 1 year), and major (therewere more nonmajors in the othercourses), but no other demographic char-acteristics.

Class DescriptionsStudents who had passed an Introduc-

tory Psychology class and were at least intheir second year of college were able toenroll in any of these classes. Thus, whilethe intention is that students take thejunior-level courses before senior-levelcourses, professors must design all of theseclasses so that students can succeed withonly minimal background knowledge. Allclasses had a maximum capacity of 55 stu-dents with actual enrollments rangingbetween 48–53 students per class. Allclasses met for the same length of timeacross the semester with the junior-levelcourses meeting 3 days per week for 50-minute class periods and the Psychology ofParenting class meeting twice per week for75-minute class periods.

The Psychology of Parenting class,taught by the author, was designed to teachundergraduate students relevant theoriesand research related to parenting from thepoint of considering becoming a parentthrough parenting an adolescent, as well asempirically supported parenting strategies.Students completed out-of-class readingsand assignments related to the topics andthe class met a total of 29 times, includingexamination days. The course was struc-tured so that the first nine classes weredevoted to learning about backgroundknowledge (e.g., theories of parenting) andbroad recommendations (e.g., broad rec-ommendations for parenting duringinfancy). Then eight class periods weredevoted to learning about positive parent-ing practices (e.g., use of positive reinforce-



ment and effective commands). The fol-lowing class period introduced discipline,including the potential issues with the useof punishment and how to make punish-ment more effective. The next class periodwas devoted to reviewing meta-analysesand other studies related to corporal pun-ishment. Finally, five class periods werespent learning about effective disciplinemethods (e.g., time-out and ignoring andattending).

Students in the Learning and Develop-mental Psychology classes were also taughtby the same professor (the author). Por-tions of their readings and brief portions ofclass periods were devoted to informationrelated to optimal parenting practices, thepotential negative effects of corporal pun-ishment, and some information on effec-tive parenting practices, but none of thesetopics were covered in the same depth asthe Psychology of Parenting class. TheSocial Psychology class, taught by anotherprofessor, covered aggression as a topic butdid not cover corporal punishment noreffective parenting practices.

ProcedureApproval for this study was given by the

Institutional Review Board of the large uni-versity in the southern United States wherethe study took place. A research assistantattended the end of the second day of classto inform students enrolled in the Psychol-ogy of Parenting class about participatingin the study. After receiving informationabout the study, students were given aninformation sheet and packet of question-naires. Students who consented to havetheir data used for the study were told tocomplete an optional demographic sheetand place it in a manila envelope thatwould not be opened until after final gradeshad been submitted (thus protecting themfrom potential coercion). All studentscompleted the packet of parenting ques-tionnaires during the second and last weekof classes as an out-of-class assignment andonly the data for those who had completedthe optional demographics questionnairewere utilized for this study (96% con-sented).

Students in the other classes were giveninformation about the study via anannouncement on the university’s onlinelearning platform during the first week ofclasses and were told to follow a link to aQualtrics website to give consent and com-plete the questionnaires online in order toparticipate in the study and receive credit.During the last week of classes, studentswho participated in the pre-assessment via

Qualtrics were sent an email requestingtheir participation in the postassessment.

All students who completed thepostassessment were sent an email 3months after the semester requesting theycomplete the questionnaires again for achance to win one of four $25 Amazon giftcards. Too few students completed this toanalyze the data.

Completion of this study was one ofmany options for students to receive pointsthat went towards their final grade in thecourse(s) they were enrolled in and theywere entered into a raffle for one of four$25 Amazon gift cards if they completedthe follow-up measurement 3 months later.The professors were blind to which stu-dents completed the questionnairesbecause a research assistant informed theprofessors how many points they earnedthrough any of the available methods toearn points.

QuestionnairesDEmOGRAPHICSA demographic questionnaire was cre-

ated for this study to obtain participants’age, year in school, major/minor, and pre-vious psychology courses completed. Thedemographics section of the Dimensions ofDiscipline Inventory (DDI; Straus &Fauchier, 2011) was also given and askedabout demographics such as sex and racial/ethnic identity.

PARENTING QUESTIONNAIRESThe following three questionnaires

were utilized in order to evaluate students’beliefs about parenting behaviors with dif-ferent ages of children. The questionnairesutilized also made it possible to capturestudents’ beliefs about a wide variety ofparenting behaviors.

Parenting Scale–Should (PS-Should;Rhoades & O’Leary, 2007). The PS-Shouldis a 30-item self-report questionnaire mea-suring beliefs about what parents should doin discipline situations with 2- to 6-year-olds. Participants rate what they believeparents should do in response to the givenchild misbehavior on a 7-point scale withanchors of one effective (e.g., “rarely usebad language or curse”) and one ineffectivestrategy (e.g., “almost always use bad lan-guage”). The questionnaire results in threefactors that are computed by reverse scor-ing some items and then computing themean of the relevant items. Scores thusrange from 1 to 7 with higher scores indi-cating higher levels of believing parentsshould engage in the given discipline style.The three-item Hostile factor was utilized

for this study as a measure of students’beliefs about the appropriateness of thesehostile discipline behaviors, including cor-poral punishment for young children. Thefive-item Overreactive factor was also uti-lized because this form of disciplineappears to be a final common pathway forrisk of parent-to-child aggression (Slep &O’Leary, 2007). The PS-Should has goodconstruct and predictive validity as well asgood internal consistency (Rhoades &O’Leary, 2007).

Alabama Parenting Questionnaire-Should (APQ-Should). The original Alaba-ma Parenting Questionnaire (APQ; Frick,1991) is a 42-item questionnaire designedto measure positive and problematic par-enting behaviors. The APQ has good con-struct and predictive validity and variablereliability across factors (Shelton et al.,1996). The instructions of the APQ weremodified so that the APQ-Should askedparticipants to rate how often they thinkeach of the 42 behaviors should typicallyoccur in an ideal home for a 12-year-oldchild using a 5-point scale from 1 (Never)to 5 (Always). The full psychometric prop-erties of the revised scale have not beenpreviously established, but internal consis-tency was analyzed in this sample. TheCorporal Punishment factor was utilizedfor this study to evaluate beliefs about theuse of common corporal punishmentbehaviors (e.g., spanking) for pre-adoles-cents (12-year-olds). This factor consists ofthree items and factor scores are obtainedby taking the means of relevant items, suchthat higher scores indicate higher levels ofagreement that parents should engage inthese behaviors. Spearman-Brown cor-rected alphas for this study were .60 (pre)and .69 (post) for the Corporal Punishmentfactor, which is consistent with the lowinternal consistency found for this factoron the original APQ by Shelton et al.(1996).

Dimensions of Discipline Inventory(DDI; Straus & Fauchier, 2011). The AdultRecall Form E of the DDI was used, whichmeasures participants’ opinions regardinghow acceptable they believe it is for parentsof a 10-year-old to engage in each of 26forms of parental discipline. All items arescored on a 4-point scale ranging from 1 (Ithink it is never OK) to 4 (I think it is alwaysor almost always OK) and factors are cre-ated by calculating the mean of relevantitems such that higher scores indicatehigher levels of agreement that it is okay touse the given disciplinary behaviors. Thefour-item Corporal Punishment factor was


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utilized for this study to evaluate beliefsabout the use of common and moreextreme corporal punishment behaviors,such as using objects to hit children, forchildren (10-year-olds).

ResultsA mixed model analysis of variance

(ANOVA) was computed for each of thefour outcome variables in order to exam-ine the interaction between group (parent-ing students vs. other students) and time(pre- and postassessment). During dataanalyses the violations of the assumptionsof a mixed model ANOVA were exam-ined. The within-subject equality of vari-ances assumption was violated for the postscores on the Overreactive discipline factorand the APQ Corporal Punishment factor,so the Greenhouse-Geisser corrected F sta-tistic was used for these tests. Finally,planned post-hoc within-subjects t-testswere conducted to examine the within-subjects effects across the semester for eachgroup.1

PS-Should FactorsAs can be seen in Figure 1, when the PS-

Should Hostile parenting factor was theoutcome variable, there was a significant,though small, interaction of time andgroup, F(1, 82) = 4.52, p = .04, Partial η2 =.05. There was a significant, medium effectfor parenting students, t(39) = 4.42, p <.001, d = .70, and a significant, small effectfor other students, t(43) = 2.10, p = .04, d =.32. The effect size was larger for the par-enting students, suggesting the interactionwas due to parenting students decreasingtheir support for the parenting behaviorsincluded in the Hostile factor more thanother students.

As can be seen in Figure 2, when the PS-Should Overreactive factor was the out-come variable, there was a significant,medium interaction of time and group,Greenhouse-Geisser corrected F(1, 82) =5.09, p = .03, Partial η2 = .06. There was asignificant, medium effect for parentingstudents, t(39) = 4.78, p < .001, d = .76, buta marginally significant, small effect forother students, t(43) = 1.97, p = .06, d = .30.

1Students completed the full measures for allthree questionnaires, but due to the potentialfor both short- and long-term negative effectsof corporal punishment and overreactive dis-cipline, as well as concern for Type I error,only those results are reported. Full resultsare available upon request.

Figure 1. Parenting Scale-Should Hostile Factor Scores by Group andTime. Note. Level of agreement ranges from 1 (low) to 7 (high). Error barsshow 95% confidence interval.

Figure 2. Parenting Scale-Should Overreactive Factor Scores by Groupand Time. Note. Level of agreement ranges from 1 (low) to 7 (high). Errorbars show 95% confidence interval.

Figure 3. Alabama Parenting Questionnaire-Should Corporal Punish-ment Factor by Group and Time. Note. Level of agreement ranges from 1(never) to 5 (always). Error bars show 95% confidence interval.



These results also suggest that the interac-tion was due to parenting students decreas-ing their support for the parenting behav-iors included in the Overreactive factormore than other students.

Corporal Punishment FactorsAs can be seen in Figure 3, when the

APQ-Should Corporal Punishment factorwas the outcome variable, there was a sig-nificant, large interaction of time andgroup, Greenhouse-Geisser corrected F(1,82) = 19.29, p < .001, Partial η2 = .19. Therewas a significant, large effect for parentingstudents, t(39) = 5.56, p < .001, d = .88, butno effect for other students, t(43) = -.20, p =.84, d = .03. These results suggest the inter-action was due to parenting studentsdecreasing their support for the parentingbehaviors included in the APQ-ShouldCorporal Punishment factor while theother students did not.

As can be seen in Figure 4, when theDDI Corporal Punishment Approval Scorewas the outcome variable, there was not asignificant interaction of time and group,F(1, 82) = 2.20, p = .14, Partial η2 = .03.There was a significant, large effect for par-enting students, t(39) = 5.12, p < .001, d =.81, and a significant, small effect for otherstudents, t(43) = 2.30, p = .03, d = .35. Theseresults indicate students in both groupsdecreased their support for parents’ use ofthe parenting behaviors included in theDDI Corporal Punishment factor from thebeginning to the end of the semester, butparenting students did not do so signifi-cantly more than other students.

DiscussionThere was mixed support for my

hypothesis that parenting students wouldreduce their support for parents’ use ofoverreactive discipline and corporal pun-ishment as ideal parenting behaviors morethan other students. Significant interactioneffects were found when students’ supportwas measured using the PS-Should Hostileand Overreactive parenting factors and theAPQ-Should Corporal Punishment factor,but not with the DDI Corporal Punish-ment Approval factor. One possible reasona significant interaction was not found forthe DDI Corporal Punishment factor isthat all items on this factor are directlyrelated to corporal punishment that maycause physical pain to the child, whereas allother factors include items that may notcause physical pain to the child, such asyelling at the child. The effect size of thewithin-subjects t-test for the other studentson the DDI Corporal Punishment factorwas the largest effect for this group (d =.35). So, it is possible that these moreextreme forms of corporal punishment areaddressed sufficiently in the other psychol-ogy classes so that students’ opinions ofphysical pain-inducing corporal punish-ment change more than their opinions onrelated dysfunctional discipline behaviors.

When examining changes in scoresacross the semester for each group, itbecomes clear that parenting studentsdecreased their support for the dysfunc-tional discipline behaviors included in thequestionnaires more than the other stu-dents. For all outcome variables there were

medium or large effect sizes for parentingstudents and no to small effect sizes forother students. It is interesting to note,though, that small effect sizes were foundon three out of the four outcome variablesfor the other students. This suggests that itmay be possible to reduce students’ sup-port for dysfunctional discipline behaviorsbeing considered ideal parenting behaviorsat least somewhat with minimal educationrelated to parenting behaviors such as thatprovided in the other classes (e.g., briefcoverage of recommendations for how par-ents should socialize their children). How-ever, higher levels of education, such as thatprovided to the parenting students, may berequired to reduce their support even fur-ther.

It is promising to note that students’support for the given behaviors were rela-tively low, even at the start of the semester,with all mean scores at pre-assessmentbeing below the bottom 37th percentile ofpossible scores for all outcome variables.However, support decreased on three outof four outcomes for the other students andon all four outcomes for the parenting stu-dents, even with this restricted range in thescores. This is promising because it mayindicate students are learning these are notideal parenting behaviors in earlier psy-chology classes (or from other sources) andtheir support can be reduced even morewith additional education. Future researchshould explore students’ current beliefsrelated to dysfunctional discipline and uti-lize a control group outside of psychologyto determine the effect of psychologyclasses specifically.

Atkins et al. (2015) encouragedresearchers to explore alternative means todisseminate empirically backed interven-tions. This study is one such attempt andprovides promising preliminary evidencethat our undergraduate psychology class-rooms are potential venues for meaningfulprimary prevention of dysfunctional disci-pline behaviors. Taken with the findingthat undergraduate students’ beliefs aboutacceptability of aggressive disciplinarybehaviors mediates the relation betweenaggressive discipline experienced andintent to use aggressive discipline (Fleming& Borrego, 2019), this study suggests thatby modifying students’ acceptabilitybeliefs, we may be able to modify theirintention to use aggressive discipline tac-tics, and potentially the likelihood that theydo so. Therefore, the results of this pilotstudy, demonstrating that enhancedcoursework in parenting can successfullymodify students’ attitudes, suggests further

Figure 4. Dimensions of Discipline Inventory Approval for Corporal Pun-ishment Factor by Group and Time. Note. Level of approval ranges from1 (never OK) to 4 (always or almost always OK). Error bars show 95% con-fidence interval.

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research into whether undergraduatecoursework in parenting can modify cur-rent or future behavior is warranted.Future research should attempt to includemore students who are currently parents inaddition to potential future parents inorder to first determine whether course-work successfully modifies current behav-iors. If the results of such a study arepromising, it would be beneficial to con-duct a longitudinal study following stu-dents who are not currently parents untilthey are parenting a child to determine ifthere are any impacts on future parentingbehaviors.

A final strength of the present study tonote is it provides preliminary psychomet-ric support for the APQ-Should. This studydemonstrates that the APQ-Should can besuccessfully utilized to evaluate students’beliefs about what parents should do andthe measure is sensitive enough to detectchanges in beliefs over time. Finally, thisstudy also provides an estimate of the inter-nal consistency of the Corporal Punish-ment factor.

Limitations and Future DirectionsAs noted, this study is intended to be a

preliminary study designed to determine ifwe can successfully utilize our classroomsettings as a venue for primary prevention.As such, there are multiple limitations andcaveats that future research should address.

First, beliefs about what individualsshould do does not necessarily translateinto what they actually do. As Rhoades andO’Leary (2007) found, parents knew theyshould be engaging in less dysfunctionaldiscipline than they reported they didengage in. However, Rhoades and O’Learyalso found that parents’ beliefs about whatthey should do was significantly correlatedwith what they did do, so beliefs mayindeed influence actual practices. Similarly,attitudes about the appropriateness ofusing physical discipline were predictive ofthe use of physical discipline (Ateah &Durrant, 2005) and were the strongest pre-dictor of parent-to-child aggression forboth mothers and fathers in a large, repre-sentative community sample (Slep &O’Leary, 2007). Thus, the reduction of stu-dents’ beliefs that parents should useaggressive discipline tactics could influenceactual parenting behaviors and thereforehave important implications for preventingparents’ use of dysfunctional discipline andengaging in physical child abuse.

A related caveat is that this study wasconducted primarily with individuals whodo not yet have children, which made it

impossible to determine if the interventionhad any impact on their parenting behav-iors. This study indicates that these class-room educational experiences can assistindividuals to become more educatedabout the topics, raise awareness abouteffective parenting practices, and reducetheir support for dysfunctional discipline,but it remains an open question whether itwill change actual behaviors in the future.As already recommended, future researchshould attempt to follow students for alonger period of time to determine if theintervention does indeed change laterbehaviors.

The third limitation to keep in mind isthat there were some methodologicalaspects of this study that are not in line withgold-standard intervention studies. Giventhat the study was conducted in classeswhere students can freely choose whatclasses to take, students were not randomlyassigned to groups. As such, the parentingstudents were significantly older and morelikely to be psychology majors than theother students. Also, I was the professor ofthree of the four classes and therefore wasnot blind to the hypotheses. Therefore, Icannot rule out experimenter bias as apotential cause of these results. In addition,students may have forgotten that the pro-fessor would not see their responses andresponded with a social desirability bias onthe postassessment. Future research shouldattempt to replicate these results using pro-fessors blind to the hypotheses and, if pos-sible, random assignment to groups.Finally, the method through which thegroups completed the measures was differ-ent, with the parenting students complet-ing paper measures and the other studentscompleting the measures online. Futureresearch should utilize the same methodol-ogy for all participants.

ConclusionThis study provides preliminary evi-

dence that we may be able to engage ineffective primary prevention of dysfunc-tional discipline practices in our collegeclassrooms. As with all preventionresearch, it is not possible to know the fullscope of the impact immediately after thepreventive intervention. Future researchwill be needed to determine if exposingundergraduate students to empiricallybacked parenting interventions not onlymodifies their beliefs about appropriateparenting strategies, but also modifies theiractual parenting strategies if they becomeparents. This study suggests that the time

and effort required to conduct such aresearch agenda is warranted.

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Kazdin, A. E. (2005). Parent managementtraining: Treatment for oppositional,aggressive, and antisocial behavior in chil-dren and adolescents. Oxford UniversityPress.

Kessler, R. C., Demler, O., Frank, R. G.,Olfson, m., Pincus, H. A., Walters, E. E.,Wang, P., Wells, K. B., & Zaslavsky, A.m. (2005). Prevalence and Treatment ofmental Disorders, 1990 to 2003. NewEngland Journal of Medicine, 352(24),2515–2523. https://doi-org/10.1056/NEJmsa043266

merikangas, K. R., He, J., Burstein, m.,Swendsen, J., Avenevoli, S., Case, B.,Georgiades, K., Heaton, L., Swanson, S.,& Olfson, m. (2011). Service utilizationfor lifetime mental disorders in US Ado-lescents: Results of the National Comor-bidity Survey-Adolescent Supplement(NCSA). Journal of the American Acad-emy of Child & Adolescent Psychiatry,50(1), 32–45. https://doi-org/10.1016/j.jaac.2010.10.006

mingebach, T., Kamp-Becker, I., Chris-tiansen, H., & Weber, L. (2018) meta-metaanalysis on the effectiveness ofparent-based interventions for the treat-ment of child externalizing behaviorproblems. PLoS ONE 13(9): e0202855.https://doi.org/10.1371/journal.pone.0202855

Nathan, P. E., & Gorman, J. m. (Eds.)(2015). A guide to treatments that work(4th ed.). Oxford University Press.

National Center for Education Statistics.(2019, may). Undergraduate enrollment.Retrieved February 6, 2020 fromhttps://nces.ed.gov/programs/coe/indi-cator_cha.asp

Odar, C., Canter, K. S., & Roberts, m. C.(2013). Future directions for advancingissues in children’s mental health: A Del-phic poll. Journal of Child and FamilyStudies, 22(7), 903–911. https://doi-org/10.1007/s10826-012-9649-2

Rhoades, K. A., & O’Leary, S. G. (2007).Factor structure and validity of the Par-

enting Scale. Journal of Clinical Childand Adolescent Psychology, 36(2), 137 –146.https://doi.org/10.1080/15374410701274157

Sanders, m. R., Kirby, J. N., Tellegen, C. L.,& Day, J. J. (2014). The Triple P-PositiveParenting Program: A systematic reviewand meta-analysis of a multi-level systemof parenting support. Clinical PsychologyReview, 34(4), 337 – 357. https://doi.org/10.1016/j.cpr.2014.04.003

Sanders, m. R., markie-Dadds, C., &Turner, K. m. T. (2001). Practitioner'smanual for Standard Triple P. Triple PInternational Pty Ltd.

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. . .

Special thanks to Anne Overton Earwood,who collected this data for her honor’sthesis; Carrie V. Smith, who assisted withdata collection in her class; and to thereviewers for their comments, which helpedmake this manuscript stronger. Portions ofthese findings were presented at the 2019Annual Convention of the Association forBehavioral and Cognitive Therapies,Atlanta, Georgia. I have no conflicts of inter-est to disclose.Correspondence to Carey Bernini Dowling,Department of Psychology, University ofmississippi, PO Box 1848, University, mS38677-1848; [email protected].

Find a CBT Therapist

ABCT’s Find a CBT Therapistdirectory is a compilation of prac‐

titioners schooled in cognitive and

behavioral techniques. In addition

to standard search capabilities

(name, location, and area of exper‐

tise), ABCT’s Find a CBT Therapist

offers a range of advanced search

capabilities, enabling the user to

take a Symptom Checklist, review

specialties, link to self‐help books,

and search for therapists based on

insurance accepted.

We urge you to sign up for the

Expanded Find a CBT Therapist(an extra $50 per year). With this

addition, potential clients will see

what insurance you accept, your

practice philosophy, your website,

and other practice particulars.

To sign up for the Expanded Find

a CBT Therapist, click MEMBER

LoGIN on the upper left‐hand of the

home page and proceed to the

ABCT online store, where you will

click on “Find CBT Therapist.”

For further questions, call the

ABCT central office at 212‐647‐

1890.

June • 2020 183

WHAT AN EXHAUSTING, extraordinary,and tumultuous time. It is hard not to feelexhausted by the effects and inequalitiesexposed by the COVID-19 pandemic. Yet,everywhere around me I see people reach-ing for ways to help and heal. In responseto its precarity, this moment has us reach-ing out to connect with those people andvalues we hold dear.

In the midst of it all, ABCT’s mission—to foster human well-being through evi-dence-based principles—calls. As misin-formation proliferates on social mediawhile systems of medical and psychologicalhealth care strain with human suffering, Ithink about the importance of science inaddressing society’s challenges. Each year,ABCT’s Leadership and Elections Com-mittee works hard to shepherd electionswith a slate of candidates who are energizedby our organization’s mission. Consistentwith one of ABCT’s central strategic initia-tives, we seek to diversify our notions ofleadership in order to expand the kinds ofprofessionals who feel like both they andthe values they hold dear are reflected inthe organization and its leadership.

So, now more than ever, as ABCT gearsup for its 2021 election, we ask you to con-sider, what about you?

For the upcoming 2021 election, weseek nominations for ABCT’s next Presi-dent-Elect (2021–2022; President, 2022–2023; Immediate Past President, 2023–2024), Secretary-Treasurer (2022–2025),and for a Representative-at-Large (RAL;2021–2024). Each RAL serves as a liaison toone of the governing branches of the asso-ciation. The representative position openfor 2021 will connect and coordinate withthe Convention and Education IssuesCoordinator and committees. You cannominate any full member in good stand-ing in the organization and there is no limitto the number of nominees you can putforward for any position. Candidates withthe most nominations will be the only offi-cial names on the ballot once voting com-mences.

membership on the Leadership andElections Committee, approved by ABCT’sBoard of Directors, includes a chair andtwo members. Our Chair is Patricia DiBar-tolo ([email protected]), from Smith

College, who has served on the committeesince 2016. Kristen Lindgren of the Univer-sity of Washington School of medicine is acontinuing member ([email protected]), and Simon Rego, of montefioremedical Center ([email protected]), isour newest member.

If you do not have time to commit torun, we hope you will express your invest-ment in ABCT’s future by voting in theelection. One measure we track of whetherwe have hit our mark as a committee is thepercentage of members that cast votes. Lastyear, we were pleased to see one of thestrongest turnouts in years. Never compla-cent, we seek to increase rates of member-ship participation in the voting processeven further. In 2020, the election willagain run in the fall, overlapping with thetiming of our Annual Convention. markyour calendar.

For many of us, ABCT is an intellectualhome, one whose mission aligns with ourpersonal commitments. Exert your privi-leges of ABCT membership so that,together, we can realize the organization’sloftiest goals: to enhance and promotehuman health and wellness. Now morethan ever, nominate and vote. We look for-ward to hearing from you.

AT ABCT

Now More Than Ever: In Search of ABCTLeadership in 2021 and BeyondPatricia Marten DiBartolo, Chair, Leadership and Elections Committee

I nominate the following individuals:

P R E S I D E N T- E L E C T ( 2 0 2 1 – 2 0 2 2 )

R E P R E S E N TAT I V E -AT- L A R G E ( 2 0 2 1 – 2 0 2 4 )L i a i s o n t o C o n v e n t i o n & E d u c a t i o n I s s u e s

S E C R E TA RY-T R E A S U R E R ( 2 0 2 2 – 2 0 2 5 )

Nomination acknowledges an individual's leadership abilities anddedication to behavior therapy and/or cognitive therapy, empiri-cally supported science, and to ABCT. When completing the nom-ination form, please take into consideration that these individualswill be entrusted to represent the interests of ABCT members inimportant policy decisions in the coming years.

Only full and new member professionals can nominate candi-dates. Contact the Leadership and Elections Chair for more infor-mation about serving ABCT or to get more information on thepositions. Candidates for the position of President-Elect shallensure that during his/her term as President–Elect and Presidentof the ABCT, the officer shall not serve as President of a compet-ing or complementary professional organization during theseterms of office; and the candidate can ensure that their work onother professional boards will not interfere with their responsibili-ties to ABCT during the presidential cycle. Please complete andsign this nomination form. Only those nomination forms bearinga postmark on or before September 2, 2020, will be counted.

Send your form to Patricia DiBartolo, Ph.D., Leadership &Elections Chair, ABCT, 305 Seventh Ave., New York, NY 10001by Wednesday, Sept. 2, 2020. Or email [email protected] (Subject line: Nominations)

N A M E ( printed)

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4

4

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Plan to attend Thursday Ticketed Sessions

n FULL-DAY INSTITUTESJonathan S. Abramowitz, Ph.D., Ryan J. Jacoby,Ph.D., & Shannon M. Blakey, Ph.D.Desirable Difficulties: Optimizing Exposure Therapyfor Anxiety Through Inhibitory Learning

Thomas R. Lynch, Ph.D., & J. Nicole Little, Ph.D.Radically Open DBT Skills Training: It’s Not WhatYou Say, It’s How You Say It

n HALF-DAY INSTITUTES

Cory F. Newman, ABPP, Ph.D.& Danielle A. Kaplan, Ph.D.Supervision Essentials for Cognitive-BehavioralTherapy

Stefan G. Hofmann, Ph.D., Steven Hayes, Ph.D.,& David N. Lorscheid, B.S.Introduction to Process-Based CBT

Laura H. Mufson, Ph.D., & Jami Young, Ph.D.Everything You Always Wanted to Know AboutInterpersonal Psychotherapy for adolescents (IPT-A)and Never Had the Chance to Ask

Mark A. Lau, Ph.D.Fostering Resilience: An MBCT Approach for MentalHealth Professionals

Terri L. Messman-Moore, Ph.D.,& Noga Zerubavel, Ph.D.Trauma-Informed Mindfulness: IntegratingMindfulness-Based Practices Into PsychotherapyWith Traumatized Clients

Colleen E. Carney, Ph.D.Improving Access to Teen Sleep Treatments: How toDeliver Evidence-Based Techniques to Help YoungAdults Sleep Better and Feel Better

n CLINICAL INTERVENTION TRAININGS

Stephen Schueller, Ph.D.Mobile Apps for Mental Health: UnderstandingTechnologies for Use and Application in Cognitiveand Behavioral Therapies

Eli R. Lebowitz, Ph.D.SPACE: Parent Based Treatment for ChildhoodAnxiety and OCD

n AMASSJessica Schleider, Ph.D., & Michael Mullarkey,M.A. (Encore AMASS back by popular demandfrom 2019)Open Science Practices for Clinical Researchers:What You Need to Know and How to Get Started

Brian R.W. Baucom, Ph.D.Analyzing Longitudinal Data Collected During theCoronavirus Pandemic

Friday and Saturday Ticketed Sessions

n WORKSHOPSJames F. Boswell, Ph.D.,& Tony Rousmaniere, Psy.D.Deliberate Practice for Cognitive-Behavioral Therapy:Training Methods to Enhance Acquisition of CBTSkills

Steven H. Jones, Ph.D., & Elizabeth Tyler, Psy.D.Facilitating Personal Recovery in Bipolar Disorder

Melissa G. Hunt, Ph.D.CBT for GI Disorders: Clinical Training Plus Printand Digital Dissemination

June • 2020 185

Natalia A. Skritskaya, Ph.D.,& Katerine Shear, M.D.Evidence-based Treatment for Prolonged GriefDisorder

Colleen A. Sloan, Ph.D., & Danielle Berke, Ph.D.How to Apply Cognitive Behavioral Principles toTransgender Care: An Evidence-basedTransdiagnostic Framework

Glenn C. Waller, Ph.D., Carolyn B. Becker, Ph.D.,& Nicholas Farrell, Ph.D.Rediscovering Exposure: Enhancing the Impact ofCognitive Behavioral Therapy for Eating Disorders

Stefanie T. LoSavio, ABPP, Ph.D.,& Gwendolyn (Wendy) Bassett, LCSWUnraveling PTSD: Using Case Conceptualization toEnhance Identification and Targeting of Key Beliefsin Cognitive Processing Therapy

Peggilee Wupperman, Ph.D.,& Jenny “Em” Mitchell, M.A.Improving Treatment for Impulsive, Addictive, andSelf-Destructive Behaviors: Strategies FromMindfulness and Modification Therapy

Margaret Sibley, Ph.D.Engaging Teenagers with ADHD in Therapy:Motivational Strategies, Turning Skills into Habits,and Partnering With Parents

Teri L. Bourdeau, ABPP, Ph.D., Kimberly Becker,Ph.D., & Bruce F. Chorpita, Ph.D.Preparing Students as the Workforce of the Future:Managing and Adapting Practice (MAP) as aComprehensive Model for Training in Evidence-Informed Services for Youth Mental Health

J. Christopher Muran, Ph.D.,& Catherine F. Eubanks, Ph.D.Alliance-Focused Training For CBT: Strategies forImproving Retention and Outcome by Identifyingand Repairing Ruptures in the Therapeutic Alliance

Lisa W. Coyne, Ph.D., & Phoebe S. Moore, Ph.D.Acceptance and Commitment Therapy: WorkingWith Parents of Adolescents With Anxiety and OCD

Kelly Green, Ph.D., & Gregory K. Brown, Ph.D.Cognitive Therapy for Suicide Prevention

Monnica T. Williams, ABPP, Ph.D.,& Matthew D. Skinta, ABPP, Ph.D.Microaggressions in Therapy: Effective Approachesto Managing, Preventing, and Responding to Them

Brian C. Chu, Ph.D., & Laura C. Skriner, Ph.D.Coordinated Interventions for School Refusal:Advanced Skills for Working With Families andSchools

n MASTER CLINICIAN SEMINARS

Dean McKay, Ph.D.Conceptualization and Treatment of Disgust inAnxiety and Obsessive-Compulsive Disorders

Robert L. Leahy, Ph.D.Envy: A Cognitive Behavioral Approach

Gregory K. Brown, Ph.D.,& Barbara Stanley, Ph.D.The Stanley-Brown Safety Planning Intervention toReduce Suicide Risk

Richard Gallagher, Ph.D., Jenelle Nissley-Tsiopinis, Ph.D., & Christina DiBartolo, LCSWAdvancing the Functional Effectiveness of ChildrenWith ADHD at Home and School: EmpiricallySupported Programs to Build Organizational SkillsThrough Individual, Group, and School Treatments

Esme A.L. Shaller, Ph.D.AND: Adolescents Need Dialectics! LeveragingDialectical Strategies and Philosophy to Improveyour DBT With Teens and Their Families

Torrey A. Creed, Ph.D.Everything Old Is New Again: The Role ofWorksheets in Growing (and Measuring) CBTCompetence

Katherine K. Dahlsgaard, Ph.D., ABPPWhen the Feared Outcome Is Potentially Lethal:Exposures for Children With Anxiety Disorders inthe Context of Food Allergies


Outreach & Continuing Education Manager

Ever consider working at your professional home? ABCT seeks master’s or higher degree in psychology orrelated field with 2 or more years’ experience (including postdoctoral positions) following terminal degree;licensed or license-eligible.

• Academic background in population-based approaches to dissemination (e.g., MPH).• Knowledge and passion about ABCT: cognitive-behavioral orientation and commitment to science

and evidence-based principles.• Knowledge of CE principles, and familiarity with organizations that sponsor CEs.• Works well with production schedules; essential in both CE compliance and in developing the

educational programs on which they are based• Expertise in public policy related to behavioral health and in appreciation of the political issues

and participants impacting behavioral health care.• Willingness to work in NYC.• Experience with professional organizations, building partnerships, project management,

and budgeting.• Excellent communication skills including the ability to communicate effectively with membership,

prospective members, governing structure, staff, media contacts, vendors, and general public.• Expertise with information technology including social media.• Ability to multi-task, work effectively with deadlines, flexibly accommodate changing priorities

and/or goals, and produce accurate and thorough work.• Ability to work collaboratively.• Desire to work with incredible ABCT staff!

If up for the challenge, contact Mary Jane Eimer, Executive Director at [email protected]@abct.org and send yourresume and short letter on why the position appeals to you.

ABCT is committed to the national policy of equal employment opportunity. ABCT will not discriminate in its hiring, pro-motion, and/or firing of any employee on the basis of race, color, creed, religion national or ethnic origin, sex, sexualorientation, gender identity or expression, age, disability, veteran status, political affiliations, or any other characteristicprotected by law.

ABCT Seeks

June • 2020 187

| call for nominations |

This award recognizes outstanding individuals who have shown exceptional dedica-tion, influence, and social impact through the promotion of evidence-based psycho-logical interventions, and who have thereby advanced the mission of ABCT.Importantly, the goal of the award is to identify individuals who translate the impactof research into community health and well-being outside of the scope of their jobrequirements. Individuals who perform this function as part of their normal job (clini-cal or research) will not be considered for the award. Champions may not be mem-bers of ABCT at the time of their nomination.

Potential CandidatesNominees should demonstrate the characteristics of champions, broadly construed,as recognized in the implementation science literature (see Knudsen, Gutner, &Chorpita, 2019, for examples relevant to ABCT: http://www.abct.org/docs/PastIssue/42n1.pdf). Champions are those individuals who support, facilitate, diffuse or imple-ment the core assets of evidence-based interventions. Champions' efforts expand thescope and impact of evidence-based interventions beyond the reach of researchersalone. They differentiate themselves from others by their visionary quality, enthusi-asm, and willingness to risk their reputation for change. Ideal candidates should havedemonstrated the following: (1) How the individual has recognized the potential appli-cation and impact of evidence-based psychological interventions; (2) How the individ-ual has gone beyond their formal job requirements within an organization to relent-lessly promote innovation; and (3) How they actively lead positive social change.

RecognitionNominees will be reviewed in March, June, and October by the ABCT AwardsCommittee, and those meeting criteria will be forwarded to the ABCT Board ofDirectors for approval. Recipients will be notified by the ABCT President, and theirnames and photographs will be posted on the ABCT website, along with the rationalefor their recognition. Each year's champions will also be acknowledged at our annualawards ceremony at the ABCT Convention.

How to NominateEmail your nomination to [email protected] (link to nomination form is on theChampions web page). Be sure to include "Champions Nomination" in the subjectline. Once a nomination is received, an email will be sent from staff, copying theAwards and Recognition Committee Chair. The nomination will be reviewed by theAwards and Recognition Committee, and if deemed appropriate for our program, willbe forwarded to the ABCT Board of Directors for final approval. Once reviewed andapproved by the Board of Directors, the nominee will be contacted directly by thePresident, followed up with an ABCT staff member for a final review of the copy tobe posted on the ABCT website.

Champions of Evidence-Based InterventionsABCT’s 2020

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s

Visit our Champions page to see the full listings and descriptions of ABCT’s 2018 and2019 Champions.

abct.org > For Members > Champions

PRSRT STDU.S. POSTAGE

PAIDHanover, PAPermit No. 4

the Behavior TherapistAssociation for Behavioraland Cognitive Therapies305 Seventh Avenue, 16th floorNew York, NY 10001-6008212-647-1890 | www.abct.org

ADDRESS SERV ICE REQUESTED

ABCT's Academic Training and Education Standards Committee is currently soliciting nominations for theSpotlight on a Mentor program. The purpose of the Spotlight on a Mentor program is to highlight thediversity of excellent research mentors within the membership ranks of ABCT. Its goal is to spotlightpromising early-career and well-established mentors across all levels of academic rank, areas of special-ization, and type of institution. To submit a nomination, please complete the nomination form (URLbelow) and email it to [email protected] by 07/01/2020. Nominations from multiple mentees areencouraged.

ABCT's Spotlight on a Mentor program aims to highlight the diversity of excellent research mentorswithin the organization's membership ranks. Our goal is to spotlight both promising and accomplishedmentors across all levels of academic rank, area of specialization, and type of institution.

If you have any questions please email [email protected]

Nominate a mentor today: http://www.abct.org/Resources/?m=mResources&fa=spot_Mentor

SPOTL IGHTon MENTORS call for nominations

s the behaviortherapist...covid-19 is impacting how abctdoes busi-ness, but it’s not...

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