abstract: The Believe It! program developed and evaluated by Kovalski & Horan (1999) was the first interactive, multimedia, psychological-education intervention deployed on the Internet. In a controlled study, the authors reported that the ethnically diverse cartoon models were partially successful in using cognitive restructuring to promote more reasonable career beliefs among Caucasian middle-school young women. It was not clear if the program's lack of efficacy among minority young women was due to computer literacy factors affected by SES. Subsequently, three studies explored the role of matching or mismatching the ethnicity of animated agents in a graphically enhanced program with that of the young women receiving the cognitive restructuring treatment. Each of the studies used the same four outcome measures (Occupational Sex-Role Questionnaire, Believe It Measure, Career Beliefs Inventory, and the Career Myths Scale) before and after matched and mismatched participants received the Believe It! intervention. Webster (2010) analyzed data from African-American participants, Hardy (2011) Latinas, and Zhang (2013) Asian-Americans. The current study examined the matching hypothesis on a sample of ethnically isolated Caucasian young women in a rural setting. The results obtained in the three previous studies are consistent with similar research involving client and counselor dyads (e.g., Cabral & Smith, 2011). The Believe It! program had a clear impact on ethnically matched African-American young women, whereas pairings on ethnicity did not improve outcomes for either Latinas or Asian-Americans. A solitary effect on the Occupation Sex-Role Questionnaire in the current study suggests the hypothesis is worthy of further study. / Dissertation/Thesis / M.A. Counseling Psychology 2014

Background: Internet-based cognitive behavioral therapy (ICBT) for tinnitus is an evidence-based intervention. The components of ICBT for tinnitus have, however, not been dismantled and thus the effectiveness of the different therapeutic components is unknown. It is, furthermore, not known if heterogeneous tinnitus subgroups respond differently to ICBT. Aims: This dismantling study aimed to explore the contribution of applied relaxation within ICBT for reducing tinnitus distress and comorbidities associated with tinnitus. A secondary aim was to assess whether outcomes varied for three tinnitus subgroups, namely those with significant tinnitus severity, those with low tinnitus severity, and those with significant depression. Methods: A parallel randomized controlled trial design (n = 126) was used to compare audiologist-guided applied relaxation with the full ICBT intervention. Recruitment was online and via the intervention platform. Assessments were completed at four-time points including a 2-month follow-up period. The primary outcome was tinnitus severity as measured by the Tinnitus Functional Index. Secondary outcomes were included for anxiety, depression, insomnia, negative tinnitus cognitions, health-related quality of life, hearing disability, and hyperacusis. Treatment engagement variables including the number of logins, number of modules opened, and the number of messages sent. Both an intention-to-treat analysis and completer's only analysis were undertaken. Results: Engagement was low which compromised results as the full intervention was undertaken by few participants. Both the ICBT and applied relaxation resulted in large reduction of tinnitus severity (within-group effect sizes d = 0.87 and 0.68, respectively for completers only analysis), which were maintained, or further improved at follow-up. These reductions in tinnitus distress were greater for the ICBT group, with a small effect size differences (between-group d = 0.15 in favor of ICBT for completers only analysis). Tinnitus distress decreased the most at post-intervention for those with significant depression at baseline. Both ICBT and applied relaxation contributed to significant reductions on most secondary outcome measures, with no group differences, except for a greater reduction of hyperacusis in the ICBT group. Conclusion: Due to poor compliance partly attributed to the COVID-19 pandemic results were compromised. Further studies employing strategies to improve compliance and engagement are required. The intervention's effectiveness increased with initial level of tinnitus distress; those with the highest scores at intake experienced the most substantial changes on the outcome measures. This may suggest tailoring of interventions according to tinnitus severity. Larger samples are needed to confirm this.

Background: Motivation to change is a core variable in understanding and treating women with both anorexia and bulimia nervosa. The transtheoretical model (TTM) has been put forward as a framework for the assessment and treatment of motivation to change for a variety of disorders, including eating disorders. Even though motivation and ambivalence should be assessed with regard to specific symptoms in eating disorders, there is a lack of validated measures in the German language. Due to the importance of motivation to change in women with eating disorders, several studies have used the TTM to develop, and test the effectiveness of face-to-face motivational programs for this clientele. However, no randomized controlled trial for an internet-based program enhancing motivation to change has been conducted. The present thesis aimed to establish symptom-specific measures of motivation to change and ambivalence, and to develop and evaluate an internet-based therapy program for women with eating disorders. Methods: Two observational studies and one randomized controlled trial including a total of N=460 women with eating disorders were performed. The first study tested the psychometric properties (reliability and validity) of a questionnaire assessing motivation to change in a sample of N= 63 inpatients. In the second study, the psychometric properties of a questionnaire assessing ambivalence in a sample of N =195 women with eating disorders were investigated. The third study comprised a randomized controlled trial with N =202 women assessing the effectiveness of an internet-based motivational program for women with eating disorders. The fourth study systematically investigated the dropout from this program using survival analysis. Results: In the observational studies, the questionnaires showed satisfactory psychometric properties, with good reliabilities and validities. The randomized controlled trial showed significant time x group interactions, demonstrating that the internet-based program was effective in enhancing motivation to change, and in reducing some eating disorder symptoms. However, the dropout from the program was 51 %, with participants with more severe eating disorder pathology and depressive mood being more likely to terminate the program prematurely. Discussion: The results demonstrate the feasibility of both symptom-specific assessment of motivation to change and measurements of ambivalence across eating disorder diagnoses, enabling novel research questions and supporting clinical work. Evidence for the efficacy of the internet-based program in enhancing participants’ motivation to change and reducing eating disorder symptoms support the wider adoption of such programs. The results from the dropout analysis offer new perspectives for future research on additional treatment modulesm for women at risk of terminating treatment prematurely.

An Internet-based tinnitus intervention for use in the USA can address barriers that weaken the provision of tinnitus-related services. Although such interventions exist, their suitability for this population was questioned. The aim of this study was to adapt an Internet-based cognitive behavioural therapy intervention (ICBT) for tinnitus to ensure its utility for a US population. The study objectives were to ensure the program’s accessibility in terms of readability, language, and cultural appropriateness. Methods: The intervention materials were redesigned and simplified to support use by a novel patient group. Readability Studio was used to evaluate reading levels using six different formula. Cultural and linguistic adaptions were identified by clinicians in the USA. Accessibility was further enhanced as the intervention materials were translated into Spanish. Results: Accessibility measures ensured all chapters had readability levels of between Grades 5-6. Cultural and linguistic adaptations were made in terms of content, vocabulary, and spelling. To improve patient engagement, adaptions were made to the interactive elements, goal setting and worksheets. Conclusion: Internet intervention materials were revised to adhere to best practice guidelines. Further studies should determine whether these changes improved self-efficacy, engagement, and aided motivation to complete the intervention.

Unguided and free e-mental health platforms can offer a viable treatment and self-help option for depression. This study aims to investigate, from a public health perspective, the real-world uptake, benefits, barriers, and implementation support needed by general practitioners (GPs). The study presents data from a spin-off GP survey conducted 2.5 years subsequent to a cluster-randomized trial. A total of N = 68 GPs (intervention group (IG) GPs = 38, control group (CG) GPs = 30) participated in the survey (response rate 62.4%). Data were collected via postal questionnaires. Overall, 66.2% of the GPs were female. The average age was 51.6 years (SD = 9.4), and 48.5% of the GPs indicated that they continued (IG) or started recommending (CG) the e-mental health intervention under real-world conditions beyond the trial. A number of benefits could be identified, such as ease of integration and strengthening patient activation in disease management. Future implementation support should include providing appealing informational materials and including explainer videos. Workshops, conferences, and professional journals were identified as suitable for dissemination. Social media approaches were less appealing. Measures should be taken to make it easier for health care professionals to use an intervention after the trial and to integrate it into everyday practice.

The skill of savoring is one practice from the positive psychology literature that appears to facilitate well-being and happiness (e.g., Cazanescu, Tecuta, Candea, & Szentagotal-Tartar, 2018). Given such findings and the emerging evidence in favor of delivering positive psychology interventions via the Internet (Layous, Nelson, & Lyubomirsky, 2013), the potential feasibility of providing researched-based savoring instruction using self-directed online resources warrants empirical examination. This pilot study examined the feasibility of a self-directed online module of instruction and exercises intended to aid in cultivating individuals’ savoring abilities. The two primary aims of the present study were: 1) to examine the feasibility and preliminary outcomes of delivering an online 21-day savoring intervention through the website www.mybestself101.org (Savoring Module), and 2) to collect descriptive/qualitative feedback on the module content for further improvement of these resources. A supplemental aim was to establish convergent validity of the newly developed Savoring Questionnaire with an existing measure of savoring beliefs. Results indicated that participants completing the 21-day self-directed content and exercises in the Savoring Module reported positive and significant changes in savoring skills and subjective well-being. However, only 22% of consenting participants completed the 21-day sequence of content and exercises on their own. The majority of participants who completed the study found both the informational content and the strategies of the module to be "very helpful" or "extremely helpful." Overall, findings indicate that a self-directed savoring intervention delivered via the Internet can produce an increase in savoring skills and subjective well-being.

Clinical and subclinical eating pathology are common, especially among female undergraduates. Such problems are often chronic and associated with a range of negative medical and psychological outcomes. Thus, it is important to develop effective prevention programs to reduce eating disorder risk. Numerous studies suggest that dissonance-based prevention programs are the most successful in reducing eating disorder risk factors, however, such programs might not be convenient for students limited by scheduling restraints or geographic proximity. Further, some students may be reluctant to attend such groups due to lack of anonymity. One way to address these potential barriers is to adapt dissonance-based programs for online use. However, no extant studies have examined the feasibility of this mode of delivery for dissonance-based programs. The current study examined the effectiveness of an online dissonance-based program, and compared it with traditional face-to-face delivery and assessment-only control conditions. It was hypothesized that: 1) online and face-to-face dissonance programs would produce comparable results; and 2) both of these active treatments would yield improvements in eating disorder outcomes (e.g. reduced thin ideal internalization, body dissatisfaction, dieting, negative affect, and eating disorder symptoms) compared with an assessment-only control condition. Results partially supported the original hypotheses. Modified intent-to-treat analyses (MITT) indicated that participants in both the face-to-face and online intervention groups showed less body dissatisfaction at post-intervention assessment compared to assessment only participants. Further, when analyses were conducted using a non-intent-to-treat (non-ITT) approach (examining only the outcomes of participants who completed the intervention), significant post-intervention differences were observed for all outcome variables. Specifically, individuals in both intervention groups showed lower thin-ideal internalization, body dissatisfaction, restraint, negative affect, and fewer eating disorder symptoms compared to assessment only participants. This study indicates that there may be some promise in adapting dissonance-based eating disorder prevention programs for online use. Future studies should continue to refine online adaptations of such programs and examine the effects of such programs with different populations.

BACKGROUND: Tinnitus is a symptom that can be very distressing owing to hearing sounds not related to any external sound source. Managing tinnitus is notoriously difficult, and access to evidence-based care is limited. Cognitive behavioral therapy (CBT) is a tinnitus management strategy with the most evidence of effectiveness but is rarely offered to those distressed by tinnitus. The provision of internet-based CBT for tinnitus overcomes accessibility barriers; however, it is not currently readily available in the United States. OBJECTIVE: The aim of this study is to investigate the efficacy of internet-based CBT compared with that of weekly monitoring for the management of tinnitus in reducing tinnitus distress; reducing tinnitus-related comorbidities, including tinnitus cognitions, insomnia, anxiety, and depression; and assessing the stability of the intervention effects 2 months after the intervention. METHODS: A 2-arm randomized clinical trial comparing audiologist-guided internet-based CBT (n=79) to a weekly monitoring group (n=79) with a 2-month follow-up assessed the efficacy of internet-based CBT. Eligible participants included adults seeking help for tinnitus. Recruitment was conducted on the web using an open-access website. Participants were randomized via 1:1 allocation, but blinding was not possible. The study was undertaken by English or Spanish speakers on the web. The primary outcome was a change in tinnitus distress as measured using the Tinnitus Functional Index. Secondary outcome measures included anxiety, depression, insomnia, tinnitus cognition, hearing-related difficulties, and quality of life. RESULTS: Internet-based CBT led to a greater reduction in tinnitus distress (mean 36.57, SD 22) compared with that in weekly monitoring (mean 46.31, SD 20.63; effect size: Cohen d=0.46, 95% CI 0.14-0.77) using an intention-to-treat analysis. For the secondary outcomes, there was a greater reduction in negative tinnitus cognition and insomnia. The results remained stable over the 2-month follow-up period. No important adverse events were observed. Further, 16% (10/158) of participants withdrew, with low overall compliance rates for questionnaire completion of 72.3% (107/148) at T1, 61% (91/148) at T2, and 42% (62/148) at T3. CONCLUSIONS: This study is the first to evaluate and indicate the efficacy of audiologist-delivered internet-based CBT in reducing tinnitus distress in a US population. It was also the first study to offer internet-based CBT in Spanish to accommodate the large Hispanic population in the United States. The results have been encouraging, and further work is indicated in view of making such an intervention applicable to a wider population. Further work is required to improve compliance and attract more Spanish speakers. TRIAL REGISTRATION: ClinicalTrials.gov NCT04004260; https://clinicaltrials.gov/ct2/show/NCT04004260.