the promises and pitfalls of a modularized intervention ... · stew shankman consultants ... steve...

12/9/2019

1

Alyson K. Zalta, PhDAssistant Professor

University of California, Irvine

The Promises and Pitfalls of a Modularized Intervention Approach to Promote Resilience

Alyson K. Zalta, PhDAssistant Professor

University of California, Irvine

K23 MH103394

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

12/9/2019

2

How do we intervene?

Treat psychopathology○ Emphasis on reduction of current

distress○ Intervene based on symptom

manifestation○ Deliver to those with diagnoses

“Mental health promotion includes efforts to enhance individuals’ ability to achieve

developmentally appropriate tasks (competence) and a positive sense of self-esteem, mastery, well-being, and social inclusion and to strengthen their

ability to cope with adversity.”

Enhance resilience○ Emphasis on enhancing skills to

buffer against stress○ Intervene based on underlying

processes○ Deliver to those at risk

12/9/2019

3

What makes people resilient?

EmotionsCognition

Behavior

Biology

Relationships

CommunityResources

Policy

Profiles of resilience

My name is Ella- I am very grateful for the good things in life- I am willing to try things that are hard and stick to it- I have trouble telling people no and setting limits- I worry about other people and what they think of me- When I get upset, I feel overwhelmed by my emotions, but get over it relatively quickly

My name is Rylee- I am very social and have a lot of friends

- I tend to think positively about myself and others

- I have a number of fears and experience tension in my body

- I avoid things that are new or unpredictable

- When I get upset, I go for a run and shake it off

My name is Griffin- I am curious about the world and eager to try new things

- I am direct in telling people my needs / wants

- I tend to jump to negative conclusions

- I get sucked up in electronics and don’t socialize as a result

- When I get upset, I act out & the feelings persist for a long time

12/9/2019

4

What is a Modular Intervention?

● Modularity = ‘breaking complex activities into simpler parts that may function independently”

● Modules = “self-contained functional units that connect with other units, but do not rely on those other units for their own stable operations”

Chorpita et al., 2005

● Properties of Modularity○ Partial decomposability – a complex system may be divided into meaningful

functional units (e.g., sessions)

○ Proper functioning – the operation of each module in the design is expected to produce the intended result (e.g., relaxation module reduces client arousal)

○ Standardized interface – modules communicate with each other in a structured fashion

○ Information hiding - the details of operation are fully contained within the module.

Potential benefits of modularized interventions

● Flexibility○ Content ○ Length

● Matching

● Ease of dissemination

● Opportunity for empowerment?○ Patient preference predicts engagement / outcomes ○ Individuals with CIT are likely to feel disempowered

12/9/2019

5

Challenges of Modularized Interventions: Module selection & sequencing

clinician patient

algorithmcombination

Modularized Cognitive-Behavioral Resiliency Training (MCBRT) – A Healthy Mind Intervention

● Goals: skills learning & enhancement of self-efficacy

● Opening session○ Overview and rationale○ Develop a personalized resilience plan (module selection)○ Introduce the Action Plan – assignment 1 is identifying strengths○ Feedback

● Module session structure○ Action Plan review and Lessons Learned (beginning of next session)○ Psychoeducation & conceptualization○ In-session practice○ Action Plan development

● Closing session○ Review and plan for the future

Adapted from Meichenbaum, 2012

12/9/2019

6

My Action Plan

This week I am working on: _____________________________

I will practice this skill by:

These are the days and times I will practice this skill:

What will help me complete my plan? What strengths could I use?

What might get in the way of my plan? Are there any practical or emotional barriers?

How can I set myself up for success, even if these issues come up?

If I get stuck in carrying out my plan, I will ask myself one of these questions:- What is the smallest change I can make in this area?- How does working on this plan connect to my bigger goals?- How will I feel if I accomplish this task?- Who can help me accomplish my goals?

MCBRT Modules

Module Introductory Session Advanced Session

Increasing pleasurable and meaningful activities

Activity schedulingDefining values and linking

values to activities

Enhancing relaxation Diaphragmatic breathing Positive imagery

Managing negative emotionsObserving and describing

emotionsIdentifying and engaging in

opposite actions

Decreasing negative thinking patterns 5-column thought record 7-column thought record

Creating positive thinking habits Gratitude journal Expressing gratitude

Eliminating avoidance Exposure Embracing uncertainty

Setting and achieving goals SMART goalsAdapting goals & linking short to long-term goals

Decreasing unhealthy habits Chain analysisDecreasing vulnerabilities

& breaking weak links

Learning to let go Leaves on a StreamCompassion toward self

and others

Improving communication DEARMANPrioritizing interpersonal

goals

12/9/2019

7

The Resilience Checklist

How much do you communicate directly and openly with others?

1--------2--------3--------4--------5--------6--------7--------8--------9--------10not at all extremely

Do you think the ability to communicate directly with others would help youbounce back from stress?


How much do you want to work on direct communication as part of your Healthy Mind program?


Direct communication: Individuals who are resilient are able to manage their relationships well by directly sharing their needs, asking for help, and saying “no.” Direct communication helps manage stress by enabling you to ask for what you need from others. It can also help prevent situations where you might feel overwhelmed or taken advantage of. Signs that working on this item might benefit you: you have a hard time setting limits, saying no, or asking for what you need from others.

Pilot Randomized Trial

● Participants randomly assigned to 8-week MCBRT or health education control○ For MCBRT, subjects selected 3 modules

● Inclusion Criteria○ 18 years or older○ History of childhood interpersonal trauma○ Reporting at least mild distress on the DASS-21

● Exclusion Criteria○ Trauma in the past month○ Lifetime psychotic or bipolar disorder○ Substance use disorder in past 6 months○ Active suicidal ideation or suicidal behaviors in past 6 months○ Concurrent psychotherapy○ Psychiatric meds must be stable○ Serious medical illness, auditory impairment, color blindness

12/9/2019

8

Health Body Protocol (control condition)

● 8 week protocol focused on providing information about good health practices to promote resilience

● Fixed Modules○ Introduction: the Mind-Body connection○ Nutrition Dos○ Nutrition Don’ts ○ Exercise○ Everyday Addictions○ Sleep○ Preventing Illness○ Preventive Care and Wrap-Up

● Coaches instructed to establish rapport and use active listening while avoiding problem solving / goal setting

Outcomes

● Psychological○ Resilience (CD-RISC)○ Emotion Regulation (DERS)○ Symptoms (DASS-21)○ Functioning (WSAS)

● Physiological○ Fear conditioning

● Biological○ Neuropeptide Y○ Dehydroepiandosterone (DHEA)○ Allopregnanolone

12/9/2019

9

Sample Characteristics

Variable n(%)

Gender

Male 13 (26.0)

Female 36 (72.0)

FtM transgender 1 (2.0)

Hispanic or Latino 4 (8.0)

Race

Caucasian / White 23 (46.0)

African American 22 (44.0)

Other 3 (6.0)

Decline to answer 2 (4.0)

Income

<$30K 23 (46.0)

$30K-69K 11 (22.0)

$70K+ 13 (26.0)

Don’t know / decline 3 (6.0)

Variable M SD(range)

Age 43.6 15.9(20 – 74)

CTQ emotional abuse(mod: 13-15, sev = 16+)

15.20 6.18(5 – 25)

CTQ physical abuse(mod: 10-12)

11.24 5.43(5 – 25)

CTQ sexual abuse(mod: 8-12)

11.04 6.76(5 – 25)

PCL-5(clinical cutoff: 31)

27.0 14.8(1 – 62)

DASS - Depression(mild: 10-13)

11.80 8.06(0 – 36)

DASS - Anxiety(mild: 8-9)

8.86 6.63(0 – 24)

DASS - Stress(mild: 15-18)

15.18 8.38(2 – 36)

Subject flowAssessed for eligibility

(n = 102)

Assigned to MCBRT (n = 25)

- completers (n = 15)

Assigned to control (n = 25)


Crossed over to MCBRT (n = 13)


Excluded (n=52)

- Not meet inclusion criteria (n=30)

- Could not complete screen (n=3)

- Could not contact/schedule (n=14)

- Other reasons (n=5)

😢?

12/9/2019

10

22 (58%)

16 (42%) 16 (42%)15 (39%)

11 (29%) 11 (29%)

7 (18%) 7 (18%)6 (16%)

5 (13%)

0

5

10

15

20

25

Nu

mb

er o

f p

arti

cip

ants

Frequency of Modules Selected

Checklist Ratings for Selected & Unselected Modules

Selected Unselected

n M SD M SD t d

Current Use 38 4.61 1.88 5.90 1.36 -4.75** -.77

Helpfulness 38 8.67 1.55 7.88 1.51 4.33** .51

Willingness 38 8.68 1.48 7.61 1.93 3.72** .61


**p < .01

12/9/2019

11

What about clinician selection?

● SCID assessors picked 3 modules they would recommend for each subject○ On average, selected 1.18 modules correctly (SD = 0.65)○ 0 correct picks (13%), 1 correct pick (55%), 2 correct picks (32%)

● MCBRT coaches picked 3 modules they would recommend for each subject before reviewing the resilience checklist○ On average, selected 1.71 modules correctly (SD = 0.80)○ 0 correct picks (5%), 1 correct pick (34%), 2 correct picks (45%),

3 correct picks (16%)

What predicted MCBRT dropout?

Completern = 15

Dropoutn = 10

M SD M SD d

Treatment expectancy 3.00 0.85 2.78 0.83 -.27

Self-mastery 21.39 3.40 22.6 2.91 .38

BPD characteristics 3.80 2.60 3.50 2.22 -.12

Childhood trauma severity 62.80 27.18 57.90 22.90 -.19

DERS total 85.30 28.26 74.07 18.36 -.45

CD-RISC total 65.08 16.91 67.80 15.25 .17

12/9/2019

12

What predicted MCBRT dropout?

Completern = 15

Dropoutn = 10

M SD M SD d

Current Use – All mods 5.05 1.15 5.72 1.38 .53

Current Use – Selected mods 3.96 1.50 4.37 2.51 .21

Helpfulness – All mods 8.78 1.11 8.12 1.76 -.47

Helpfulness – Selected mods 9.53 0.74 7.73 3.20 -.81*

Willingness – All mods 8.39 1.53 8.30 1.93 -.06

Willingness – Selected mods 9.20 1.19 7.77 3.22 -.63

Intervention Outcomes for Randomized Groups

12/9/2019

13

Satisfaction data for completers

MCBRTn = 16

Controln = 20

M SD M SD t

How satisfied are you with the program?

3.38 0.96 2.80 0.89 -1.86

How much do you think you benefited from the program?

3.25 0.93 2.25 1.12 -2.87**

How much have you changed your behavior based on what you learned in the program?

3.00 1.03 1.60 1.05 -4.01***

0 = Not at all, 1 = Slightly, 2 = Moderately, 3 = Very, 4 = Extremely

Conclusions & Future Directions

● Resilience Checklist may be a useful tool for identifying intervention strategies & likelihood of treatment engagement

● Confidence in module selection appears to be an important predictor of engagement

● Modularized format can be useful for brief delivery of skills

○ My postdocs say they still use the manual!

● How to promote engagement with modularized interventions?

12/9/2019

14

Acknowledgments

● Mentors○ Mark Pollack○ Stevan Hobfoll○ Stew Shankman

● Consultants○ Barbara Rothbaum○ Luan Phan○ Joe Ruzek○ Steve Southwick○ Sue Mineka○ Don Meichenbaum

● Funding○ NIMH K23 MH103394

● Participants

● Research Team○ Dale Smith○ Randy Boley○ Michelle Kaufman○ Claire Dowdle○ Linzy Wagner○ Crissy Glover○ Adam Horwitz○ Ann Rufa○ Blake Schroedter○ Lynne Lieberman○ Huiting Liu○ Haley Ford○ Seth Solway○ Vanessa Tirone

[email protected]

the promises and pitfalls of a modularized intervention ... · stew shankman consultants ... steve...

Documents