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Trial registered on ANZCTR

Registration number

ACTRN12622000847718

Ethics application status

Approved

Date submitted

16/02/2021

Date registered

16/06/2022

Date last updated

26/09/2022

Date data sharing statement initially provided

16/06/2022

Type of registration

Prospectively registered

Titles & IDs

Public title

A process-based psychological treatment informed by relational frame theory for people who meet criteria for multiple psychiatric disorders

Scientific title

Verbal Behavior Analysis informed by Relational Frame Theory on a comorbid sample within the areas of depression, anxiety and Obsessive Compulsive Disorder - A mixed methods design with multiple baseline design with six clients and interpretative phenomenological analysis to test feasibility, acceptability and effectiveness.

Secondary ID [1]

None

Universal Trial Number (UTN)

Trial acronym

Linked study record

Health condition

Health condition(s) or problem(s) studied:

Major Depressive Disorder

Panic Disorder

Agora Phobia

Social Anxiety Disorder

Obsessional Compulsive Disorder

Post-Traumatic Stress Disorder

Generalised Anxiety Disorder

Condition category

Condition code

Mental Health

Anxiety

Mental Health

Depression

Mental Health

Other mental health disorders

Intervention/exposure

Study type

Interventional

Description of intervention(s) / exposure

This study evaluates a psychological treatment (verbal functional analysis) informed by Relational Frame Theory (RFT) on a comorbid sample within the areas of depression, anxiety and obsessive compulsive disorder (OCD)

Participants meet therapists face-to-face individually at a health care center or a psychiatric outpatient clinic depending on the region of inclusion, for maximum 30 consecutive weeks, 1-2 sessions a week, one hour at the time.

The treatment is idiographical and principle based (operant learning according to an updated account of relational frame theory). The instruments for measuring the process aim to assess and influence participants maladaptive relating around themselves and others.

Note that the following text include behavioral concepts from modern relational frame theory that may seem foreign or strange. Even though examples are routinely offered, a complete elaboration or translation is not be viable in this context. The following article may aid readers not accustomed to relational frame theory and the particular behavioral language accompanying it: Barnes-Holmes, D., Barnes-Holmes, Y., & McEnteggart, C. (2020). Updating RFT (more field than frame) and its implications for process-based therapy. The Psychological Record, 1-20.

Key properties of patterns of verbal behavior are assessed through dialogue throughout the treatment.

Clients often come into therapy asserting a specific problem (e.g., “I feel depressed”). These approached self-labels may also possess avoidance functions of safety, justification, or comfort relative to a more distressing or aversive relational network (.e.g. I’m worthless or unlovable). As such, these seemingly aversive verbal stimuli (“I’m depressed”) have relatively appetitive functions. When conducting a verbal functional analysis, we assess both relatively appetitive and relatively aversive relational networks. That is, appetitive networks have dominant approach or S+ functions (approached), while more aversive networks have dominant avoidance or S- functions (avoided).

A key part of the verbal functional analysis involves identifying the relationship between the deictic-I network (i.e., the network through which the perspective I-HERE-NOW emerge) and the S+ and S- networks. This assessment is conducted in parallel to the assessment of the S+ and S- networks and offers guidance on whether there is a stable deictic-I from which the client responds. In essence, assessing the deictic-I involves assessing how that network is related to other networks. For example, is the client’s deictic-I completely coordinated with a certain network in which there are no instances of choosing hierarchically (e.g., “I am completely hopeless so there is no point at all to try that again” vs. “I notice discouraging thoughts and feelings and I must choose what to do in their presence). Said in other words, the therapist and the client build a new narrative about the client and the old narrative to facilitate adaption.

The therapist actively engages in building a strong therapeutic relationship with the client. The therapist engages in creating coordinated narratives with the client allowing for derivations such as “my therapist understand and care about me, maybe I’m not completely hopeless after all”. Relating between the deictic-I and deictic-Others is promoted by validating the client’s narrative which involves both reflecting what has been said and in addition the therapist needs to make sure the client experiences a shared understanding and a witness to the narrative of why the client did what they did, what they experienced, in specific situations. The therapist offers contextual cues for hierarchical relating between the deictic-I and the narrative that exercises control as well as for the coordinating of narratives between the therapist and the client with phrases such as “sitting here now, hearing how it all played out back then, I can see how frustrated you must have been. If I was in your shoes, I would have felt that too”. A therapeutic relationship that is stable, predictable and consistent is essential for altering functions in previously avoided networks. The therapist should provide a highly shared and cooperative context over a longer time when needed so that a more stable coherent deictic-I may be established. If the clients deictic-I is coherent and basically hierarchically situated, but present circumstances move the deictic-I to relate to events in a non-hierarchical relation (e.g., coordination), then, shorter time may be needed to re-establish a stable deictic-I as described above.

In establishing verbal tracking of the causal relations between the deictic-I and other relational networks (e.g., S+ and S-), it is essential that these two sets of networks (i.e. the deictic-I and S+ / S-) come to participate in a hierarchical relation. Specifically, the network of the deictic-I should contain the networks that relate causally to behavior. The deictic-I can then “choose” how to behave. Ultimately, clients are not relating to themselves as victims of their context, but as capable of choosing directions of their lives, even in the presence of intrusive thoughts and pain.

Once the S- network has been identified, we orient very carefully toward it, as this will likely challenge the therapeutic relationship. At this point, the coherence within the S+ and S- networks are high but they aren’t related (e.g., the client does not see how “I must over-perform” participates in a relationship with “I’m worthless), so the therapist aims to help the client relate the two networks in order to allow for transformation of functions within the networks (i.e. it may no longer make sense to over-perform when it mainly serves to prove that one is not worthless yet ironically facilitates it over and over again. This is achieved by establishing causal relations between these two networks. For example, the therapist might say “it must be truly exhausting to put so much energy into always proving that you are not worthless? A little like scooping water from a boat in order to prove that it’s not sinking instead of dealing with the holes and get to sailing?”. For the client, this statement relates the S+ and S- networks facilitating a transfer of the less aversive functions of the S+ network to the more aversive S- network, in so far as the client becomes more willing to talk about rejection and worthlessness. To further this move, the therapist might say, for example, “What if rejection lay at the end of this line of overperforming? What if overperforming and everything that comes with it actually hurt your relationships? If you had to choose between proving that you are great and having genuine relationships, which one would you choose?” Doing this facilitates a strong therapeutic relationship that allows the therapist to focus on issues that may be highly sensitive and deeply entangled in the client’s history and current situation, and which if broached too early in therapy could undermine the relationship. In a more general way, getting clients to engage with issues they have tended to avoid is important for moving toward building successful tracking of sources of behavioral control.

Both therapists in this study are licensed psychologists with minimum 7 years experience, whereas one phd and one graduate student, both in clinical psychology and with a background in behavior therapy/contextual behavioural science and relational frame theory.

Intervention code [1]

Behaviour

Intervention code [2]

Treatment: Other

Comparator / control treatment

Participants serve as their own control condition in single case experimental designs. The baseline measurements are compared to the measurements done during the intervention phase. The baseline length is randomised between 7 and 21 days.

Control group

Active

Outcomes

Primary outcome [1]

Daily idiographic assessment (DIA)
The daily idiographic assessments (DIA) consists of four questions that assess the participants relating, orienting evoking functions and verbal tracking inferred from relational fram theory. The scale was designed specifically for this study.

CONSIDER THE LAST DAY

Orienting

How often do the things that you are trying to work through come to mind?
0 = Not at all often - 10 = All the time

Relating

Describe below the issues, struggles or difficulties that you have spent most time trying to resolve?
textbox

Evoking

How willing would you be to tell numerous people you know about the things that you are trying to figure out?
0 = Not at all willing - 10 = completely willing

Verbal tracking

In addition to your struggle, do you believe that you have enough headspace and energy to comfortably manage other aspects of your life?
0 = No space at all - 10. Plenty of space

Timepoint [1]

Daily measures during baseline phase (7-21 days prior to treatment), during treatment phase (30 weeks) and one week post treatment as well as one week during follow-up measurements at 2 and 6 months. I.e., the daily measures will not occur between one week after the treatment has ended and until the first follow-up measurements are conducted. Also, they will not occur between the first and the second follow-up measurement phase.

Primary outcome [2]

Weekly idiographic assessment (WIA)
The weekly idiographic assessment consists of 6 questions that assess shifts in the dimensions of relating and choice inferred from relational frame theory.
The scale was designed specifically for this study.

CONSIDER THE LAST WEEK

Flexibility

Do you always think the same way about what you are trying to sort out?
0 = No, it differs from context to context - 10 = Yes, in all contexts

Complexity

If you were given the task of describing what you are trying to sort out in an understandable way, how much space would you need then?
0 = A few words would suffice - 10 = Very many words would be required

Derivation

Has anything new come up, that makes you look at what you are trying to sort out in a different way?
0 = no, not at all - 10 = very much new has been added

Coherence

Have you figured out (or found) that something you previously thought about X might not be true?
0 = No, not at all - 10 = Yes, all

Valued action (Choice)

Have you noticed any experiences, behaviours or even just thoughts and feelings that you had this week that seemed different to you?
0 = Not at all - 10 = Yes, everything is different now

Describe (concisely) what has been different:
textbox

Timepoint [2]

Weekly measures during baseline phase (7-21 days prior to treatment), during treatment phase (30 weeks) and once post treatment as well as once during follow-up measurements at 2 and 6 months. I.e., the weekly measures will not occur between one week after the treatment has ended and until the first follow-up measurements are conducted. Also, they will not occur between the first and the second follow-up measurement.

Secondary outcome [1]

The Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001) is used to assess for symptoms of depression.

Timepoint [1]