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  • 1. Andersson, Gerhard
    et al.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Rück, Christian
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Guided Internet-delivered CBT: Can it really be as good as seeing a therapist?2015In: The Behavior Therapist, ISSN 0278-8403, Vol. 38, no 5, 123-126 p.Article in journal (Refereed)
  • 2.
    Boettcher, Johanna
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology. Freie Universitaet Berlin, Germany.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Side effects in Internet-based interventions for Social Anxiety Disorder2014In: Internet Interventions, ISSN 2214-7829, Vol. 1, no 1, 3-11 p.Article in journal (Refereed)
    Abstract [en]

    Internet-based interventions are effective in the treatment of various mental disorders and have already been integrated in routine health care in some countries. Empirical data on potential negative effects of these interventions is lacking. This study investigated side effects in an Internet-based treatment for Social Anxiety Disorder (SAD).

    A total of 133 individuals diagnosed with SAD took part in an 11-week guided treatment. Side effects were assessed as open formatted questions after week 2 and at post-treatment after week 11. Answers were independently rated by two coders. In addition, rates of deterioration and non-response were calculated for primary social anxiety and secondary outcome measures (depression and quality of life).

    In total, 19 participants (14%) described unwanted negative events that they related to treatment. The emergence of new symptoms was the most commonly experienced side effect, followed by the deterioration of social anxiety symptoms and negative well-being. The large majority of the described side effects had a temporary but no enduring negative effect on participants' well-being. At post-treatment, none of the participants reported deterioration on social anxiety measures and 0–7% deteriorated on secondary outcome measures. Non-response was frequent with 32–50% for social anxiety measures and 57–90% for secondary outcomes at post-assessment.

    Results suggest that a small proportion of participants in Internet-based interventions experiences negative effects during treatment. Information about potential side effects should be integrated in patient education in the practice of Internet-based treatments.

  • 3.
    Bystedt, Samuel
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Boettcher, Johanna
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Clinicians' Perspectives on Negative Effects of Psychological Treatments2014In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 43, no 4, 319-331 p.Article in journal (Refereed)
    Abstract [en]

    Negative effects of psychological treatments is a fairly unexplored area of clinical research. Previous investigations have indicated that a portion of all patients experience negative effects in terms of deterioration and various adverse events. Meanwhile, evidence suggests that many clinicians are untrained in identifying negative effects and unaware of the current research findings. The objective of the current study is thus to investigate clinicians' own perspectives and experiences of possible negative effects of psychological treatments. An invitation to participate in an anonymous online survey consisting of 14 open-ended questions was distributed via three mailing lists used by clinicians that primarily identify themselves as cognitive behavior therapists. The responses were analyzed using a qualitative method based on thematic analysis. In total, 74 participants completed the survey. A majority agreed that negative effects of psychological treatments exist and pose a problem, and many reported having experienced both deterioration and adverse events among patients in their own practice. The thematic analysis resulted in three core themes: characteristics of negative effects, causal factors, as well as methods and criteria for evaluating negative effects. The clinicians recognize that negative effects exist, but many are unaware of the current research findings and are unfamiliar with methods and criteria for identifying and preventing deterioration and adverse events. The results provide evidence for further dissemination of the present knowledge regarding negative effects, particularly during basic clinical training, as well as the need for raising awareness of the available methods for identifying and preventing negative effects.

  • 4.
    Bystedt, Samuel
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Practicing clinicians' understanding and experiences of negative effects in psychotherapy2014Conference paper (Refereed)
    Abstract [en]

    Introduction: Research of psychotherapy has primarily focused on examining its efficacy and effectiveness for different psychiatric disorders. Hence, little is known about its potential for generating negative effects among patients undergoing treatment, even though some evidence suggest that 5-10% of all patients experience negative effects in terms of deterioration alone. Meanwhile, other types of adverse events might exist as well, e.g., social stigma, lower self-esteem, and less self-reliance. However, the knowledge of negative effects is currently scarce, and research has found that many practicing clinicians do not acknowledge that some patients might fare worse during treatment. Investigating practicing clinicians’ understanding and experiences of negative effects is therefore important in order to raise awareness of its occurrence and characteristics. Method: Participants were recruited through the Swedish Society for Behavior Therapy, the Section for Cognitive Behavior Therapy within the Swedish Psychological Association, and students attending the psychotherapist program at Stockholm University. Seventy four participants completed an online survey regarding negative effects of psychotherapy. The responses were analyzed using thematic analysis. Results: A majority of the participants believed that negative effects of psychotherapy exist, and some had personal experiences of patients encountering adverse events during treatment. Few received information about negative effects during their basic training in psychotherapy. Common negative effects were described as discomfort, lack of treatment effect, deterioration, dependency, and invasiveness. Possible causal factors were incompetence or inadequately applied methods, harmful treatment interventions, insufficient working alliance, among others. Only one participant was able to mention methods for monitoring negative effects during treatment. Conclusion: Practicing clinicians recognize that negative effects could pose a problem, but few were informed of its existence during their basic training in psychotherapy or know who to monitor it during treatment, warranting an increased awareness of negative effects among future clinicians.

  • 5.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Boettcher, Johanna
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Side Effects in Internet-Based Interventions for Social Anxiety Disorder2014In: Abstracts from the 8th Medicine 2.0 Summit & World Congress, 2014Conference paper (Refereed)
    Abstract [en]

    Background: Internet-based interventions are effective in the treatment of various mental disorders and have already been integrated in routine health care in some countries. Empirical data on potential negative effects of these interventions is lacking.

    Objective: This study investigated side effects in an Internet-based treatment for Social Anxiety Disorder (SAD).

    Methods: A total of 133 individuals diagnosed with SAD took part in an 11-week guided treatment. Side effects were assessed as open formatted questions after week 2 and at post-treatment after week 11. Answers were independently rated by two coders. In addition, rates of deterioration and non-response were calculated for primary social anxiety and secondary outcome measures (depression and quality of life).

    Results: In total, 19 participants (14%) described unwanted negative events that they related to treatment. The emergence of new symptoms was the most commonly experienced side effect, followed by the deterioration of social anxiety symptoms and negative well-being. The large majority of the described side effects had a temporary but no enduring negative effect on participants’ well-being. At post-treatment, none of the participants reported deterioration on social anxiety measures and 0-7% deteriorated on secondary outcome measures. Non-response was frequent with 32-50% for social anxiety measures and 57-90% for secondary outcomes at post-assessment.

    Conclusions: Results suggest that a small proportion of participants in Internet-based interventions experiences negative effects during treatment. Information about potential side effects should be integrated in patient education in the practice of Internet-based treatments.

  • 6.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Boettcher, Johanna
    Ebert, David Daniel
    Cuijpers, Pim
    Knaevelsrud, Christine
    Ljótsson, Brjánn
    Kaldo, Viktor
    Titov, Nickolai
    Consensus Statement on Defining and Measuring Negative Effects of Internet Interventions2014In: Abstracts from the 8th Medicine 2.0 Summit & World Congress, 2014Conference paper (Refereed)
    Abstract [en]

    Background: Internet interventions have great potential for alleviating emotional distress, promoting mental health, and enhancing well-being. Numerous clinical trials have demonstrated their effectiveness for a number of psychiatric conditions, and interventions delivered via the Internet will likely become a common alternative to face-to-face treatment. Meanwhile, research has paid little attention to the negative effects associated with treatment, warranting further investigation of the possibility that some patients might deteriorate or encounter adverse events despite receiving best available care. Evidence from research of face-to-face treatment suggests that negative effects afflict 5-10% of all patients undergoing treatment in terms of deterioration.

    Objective: There is currently a lack of consensus on how to define and measure negative effects in psychotherapy research in general, leaving researchers without practical guidelines for monitoring and reporting negative effects in clinical trials. The current study therefore sought out to provide recommendations that could promote the study of negative effects in Internet interventions with the aim of increasing the knowledge of its occurrence and characteristics.

    Methods: Ten experts in the field of Internet interventions were invited to participate and share their perspective on how to explore negative effects, using the Delphi technique to facilitate a dialogue and reach an agreement. The authors discuss the importance of conducting research on negative effects in order to further the understanding of its incidence and different features.

    Results: Suggestions on how to classify and measure negative effects in Internet interventions are proposed, involving methods from both quantitative and qualitative research. Potential mechanisms underlying negative effects are also discussed, differentiating common factors shared with face-to-face treatments from those unique to treatments delivered via the Internet.

    Conclusions: We conclude that negative effects are to be expected and need to be acknowledged to a greater extent, advising researchers to systematically probe for negative effects whenever conducting clinical trials involving Internet interventions, as well as to share their findings in scientific journals.

  • 7. Ebert, D. D.
    et al.
    Donkin, L.
    Andersson, G.
    Andrews, G.
    Berger, T.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Choi, I.
    Laferton, J. A. C.
    Johansson, R.
    Kleiboer, A.
    Lange, A.
    Lehr, D.
    Reins, J. A.
    Funk, B.
    Newby, J.
    Perini, S.
    Riper, H.
    Ruwaard, J.
    Sheeber, L.
    Snoek, F. J.
    Titov, N.
    Ünlü Ince, B.
    van Bastelaar, K.
    Vernmark, K.
    van Straten, A.
    Warmerdam, L.
    Salsman, N.
    Cuijpers, P.
    Does Internet-based guided-self-help for depression cause harm?: An individual participant data meta-analysis on deterioration rates and its moderators in randomized controlled trials2016In: Psychological Medicine, ISSN 0033-2917, E-ISSN 1469-8978, Vol. 46, no 13, 2679-2693 p.Article in journal (Refereed)
    Abstract [en]

    Almost nothing is known about the potential negative effects of Internet-based psychological treatments for depression. This study aims at investigating deterioration and its moderators within randomized trials on Internet-based guided self-help for adult depression, using an individual patient data meta-analyses (IPDMA) approach.

    Studies were identified through systematic searches (PubMed, PsycINFO, EMBASE, Cochrane Library). Deterioration in participants was defined as a significant symptom increase according to the reliable change index (i.e. 7.68 points in the CES-D; 7.63 points in the BDI). Two-step IPDMA procedures, with a random-effects model were used to pool data.

    A total of 18 studies (21 comparisons, 2079 participants) contributed data to the analysis. The risk for a reliable deterioration from baseline to post-treatment was significantly lower in the intervention v. control conditions (3.36 v. 7.60; relative risk 0.47, 95% confidence interval 0.29–0.75). Education moderated effects on deterioration, with patients with low education displaying a higher risk for deterioration than patients with higher education. Deterioration rates for patients with low education did not differ statistically significantly between intervention and control groups. The benefit–risk ratio for patients with low education indicated that 9.38 patients achieve a treatment response for each patient experiencing a symptom deterioration.

    Internet-based guided self-help is associated with a mean reduced risk for a symptom deterioration compared to controls. Treatment and symptom progress of patients with low education should be closely monitored, as some patients might face an increased risk for symptom deterioration. Future studies should examine predictors of deterioration in patients with low education.

  • 8. Forsell, E.
    et al.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Svensson, A.
    Andersson, G.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Overcoming procrastination: One-year follow-up and predictors of change in a randomized controlled trial of Internet-based cognitive behavior therapy2016Conference paper (Refereed)
    Abstract [en]

    Procrastination; the purposeful delay of an intended course of action is, for many, a persistent behavior associated with reduced mood, increased stress, and poorer performance. 20 % of adults and 50 % of students experience significant difficulties with procrastination. Internet- based cognitive behavior therapy (ICBT) shows promise for several conditions, but has never been applied to procrastination. The current study examined the efficacy of ICBT for procrastination at post treatment and one-year follow-up, and investigated predictors of change.

    Method: Participants (N = 150) were randomized to 10 weeks of either guided self-help, unguided self-help, or wait-list control (receiving unguided self-help after the first treatment period). Outcome measures were the Pure Procrastination Scale (PPS), the Irrational Procrastination Scale (IPS), the Susceptibility to Temptation Scale, the Montgomery Åsberg Depression Rating Scale, the Generalized Anxiety Disorder Assessment, and the Quality of Life Inventory. Intention-to-treat was used for all statistical analyses, with mixed-effects models to assess the effect of time and group.

    Results: Moderate to large effect sizes were obtained post treatment comparing guided and unguided self-help with wait-list control, the PPS, Cohen’s d = 0.70, 95% confidence interval (CI) [0.29, 1.10], and d = 0.50, 95% CI [0.10, 0.90], and the IPS, d = 0.81 95% CI [0.40, 1.22], and d = 0.69 95% CI [0.29, 1.09]. Clinically significant change was achieved among 31.3–40.0% for guided self-help and 24.0–36.0% for unguided self-help. Neither treatment condition was superior on any outcome measure, Fs (98, 65.17-72.55) < 1.70, p > .19. One-year follow-up data has been collected and the results will be available at the time of the conference, including predictors of change.

    Conclusion: ICBT could be useful for self-reported problems of procrastination, with results at one-year follow-up and predictors of change revealing the long-term benefit and variables associated with successful treatment outcome.

  • 9.
    Forsström, David
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Nilsson, S.
    Rizzo, A.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Group versus Internet-based cognitive-behavioral therapy for procrastination: Study protocol for a randomized controlled trial2015In: Abstracts from the 7th Swedish Congress on internet interventions (SWEsrii), Linköping: Linköping University Press , 2015, 20-20 p.Conference paper (Refereed)
    Abstract [en]

    Procrastination can be defined as a voluntarily delay of an intended course of action despite expecting to be worse-off for the delay, and is considered a persistent behavior pattern that can result in major psychological suffering, which in turn can constitute a major problem for many individuals. There a not many studies available on treating procrastination. A previous Internet based RCT with guided and unguided treatment aimed to decrease procrastination yielded positive results for individuals who volunteered to receive treatment. This current study has the aim to further increase the knowledge regarding treatment for procrastination. It is a RCT comparing unguided and group treatment aimed to decrease procrastination in a student population. Demographic data from the included participants and preliminary outcome data is presented. These results are discussed and compared to the previous RCT and other studies evaluating the effect of treatment aimed to decrease procrastination.

  • 10.
    Heinrich, Sarah
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Cotter, Katherine
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Weise, Cornelia
    Treating tinnitus distress via the Internet: A mixed methods approach of what makes patients seek help and stay motivated during Internet-based cognitive behavior therapy2016In: Internet Interventions, ISSN 2214-7829, Vol. 4, no 2, 120-130 p.Article in journal (Refereed)
    Abstract [en]

    Background: Internet-based cognitive behavioral therapy (ICBT) has proven to be an effective treatment in improving patients' ability to cope with tinnitus. However, some patients prefer face-to-face therapy to ICBT, and a few studies have shown considerable dropout rates if the treatment is not guided. This renders it important to identify factors that contribute to the commencement and continuation of ICBT programs.

    Aims: Because treatment motivation and expectations are important factors in psychological treatment, the aim of our study was to investigate what leads tinnitus patients to seek out ICBT, what helps them to keep up with the treatment, and what (if any) impact these factors have on dropout rates and treatment outcomes.

    Method: 112 tinnitus patients taking part in ICBT for tinnitus responded to symptom-related questionnaires at three points in time (pre-treatment, post-treatment, and one-year-follow-up) and to a questionnaire consisting of open-ended questions about their treatment motivation and expectations before beginning treatment. Data were analyzed using qualitative content analysis, and the results were used to divide the participants into groups. The treatment outcomes of these groups were compared using t-tests, χ2-tests, and both one-factorial and mixed ANOVAs.

    Results: Four main categories emerged as factors conducive to starting treatment: 1) Targets participants wanted to address, 2) circumstances that led to participation, 3) attitudes towards the treatment, and 4) training features. Participants identified six facilitators for continuing the treatment: success, training, individual attitude, hope, evidence, and support. Naming specific tinnitus-associated problems as targets was associated with greater improvement from pre-treatment to 1-year-follow-up. Describing an active involvement in the treatment was related to increased improvement from post-treatment to follow-up.

    Conclusion: There are several motivational factors that tinnitus patients consider relevant for beginning and continuing ICBT. Particularly, focusing on specific targets that do not involve the tinnitus itself, and encouraging participants to take an active role in treatment may increase treatment effectiveness. However, further hypothesis-guided research is necessary to confirm our explorative results.

  • 11.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Nordby, Kent
    University of Tromsø.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Svartdal, Frode
    University of Tromsø.
    Domain-specific quality of life across five European countries: Cross-cultural validation of the Brunnsviken Brief Quality of life (BBQ) scale2016In: EABCT 2016 Abstract Book: Total Awareness, The European Association for Behavioural and Cognitive Therapies , 2016, 590-590 p.Conference paper (Refereed)
    Abstract [en]

    The Brunnsviken Brief Quality of life (BBQ) scale is a valid, reliable and accessible self-report measure of subjective quality of life for use with both clinical and non-clinical populations. Although the BBQ has been professionally translated from original Swedish into over thirty languages, psychometric evaluations of other language versions are so far lacking. BBQ data was collected as part of an international study on procrastination in students and employees: n = 749 from Finland, n = 599 from Sweden, n = 542 from Norway, n = 411 from Germany, and n = 315 from Italy. Weighted satisfaction ratings (score range 0-16) for each of the BBQ’s six domains (Leisure, View on life, Creativity, Learning, Friends and friendships, and View on self), along with a total sum score and Cronbach’s alphas, were calculated and compared. Samples did not differ in BBQ total scores (F[4,2611] = 1.006, p = .403). Although there were some differences between samples on specific items, these were small (total difference M = 0.00, SD = 0.74) and confidence intervals overlapped, with the exception of the German sample that rated lower Learning than all other samples (p < .05, Bonferroni-adjusted). Cronbach’s alpha ranged from 0.752 (Finland) to 0.674 (Italy). Convergent validity (as assessed by correlations with scores on the Satisfaction With Life Scale) was high, ranging from r = .64 (Finland) to r = .42 (Italy). The BBQ is a valid measure of subjective quality of life in the examined languages. There are only minor cross-country differences in the quality of life domains measured by the BBQ.

  • 12.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Linköping University.
    Furmark, Tomas
    Uppsala University.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Differential impact of performance and interaction related types of social anxiety symptoms on different quality of life domains2016In: EABCT 2016 Abstract Book: Total Awareness, The European Association for Behavioural and Cognitive Therapies , 2016, 748-748 p.Conference paper (Refereed)
    Abstract [en]

    Social anxiety disorder (SAD) is a common disorder associated with impaired quality of life (QoL), that indexes anxious distress and avoidance related to social situations. The DSM-5 features a specifier to delineate those with only performance-related social anxiety, yet little is known whether performance- and interaction-related anxieties have a differential impact on total QoL and on different QoL domains. To investigate this, we pooled screening data from eight intervention studies for SAD (n = 2017). Total sample mean age was 35.28 (SD = 12.26) and 69% were female. SAD symptoms were measured using the self-rated Liebowitz Social Anxiety Scale with items classified as measuring either performance or interaction anxiety. QoL, both total and across four domains, was measured using the Quality of Life Inventory. Data was analyzed using multiple regression models featuring the two anxiety scores as predictors, and by simulating the Performance-only specifier through 2˙2 median-split subgrouping and standard ANOVAs. Both interaction and performance anxieties were independently associated with lower QoL in general and across domains. Interaction anxiety had a larger negative impact on Personal Growth- and Achievement-related QoL than performance anxiety. The High-Performance/Low-Interaction-group rated higher Achievement-related QoL compared to the Low-Performance/High-Interaction-group (p = .012), yet groups were matched on total QoL and on other domains. Other group differences were in the expected direction.

    QoL impairments in SAD is primarily driven by number of feared social situations, and only secondarily by types of fear social situations, with interaction anxiety having a larger, negative impact on some QoL domains.

  • 13. Magnusson, Kristoffer
    et al.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Boettcher, Johanna
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    For better or worse: An individual patient data meta-analysis of deterioration among participants receiving Internet-based cognitive behavior therapy2016In: EABCT 2016 Abstract Book: Total Awareness, The European Association for Behavioural and Cognitive Therapies , 2016, 285-285 p.Conference paper (Refereed)
    Abstract [en]

    Objective: Psychological treatments can relieve mental distress and improve well-being, and the dissemination of evidencebased methods is believed to aid patients in gaining access to the right type of help. Meanwhile, Internet-based cognitive behavior therapy (ICBT) has shown promising results for many psychiatric disorders. However, research on the potential for negative effects of psychological treatments has been lacking. Method: An individual patient data meta-analysis of 29 clinical trials of ICBT (N = 2866) was performed using the Reliable Change Index for each of the primary outcome measures to distinguish deterioration rates among patients in treatment and control conditions. Statistical analyses of predictors were subsequently conducted using generalized linear mixed models. Missing data was handled by multiple imputation. Results: Deterioration rates were 122 (5.8%) in treatment and 130 (17.4%) in control conditions, yielding a total of 252 (8.8%). Patients in a control condition had higher odds of deteriorating, Odds Ratios (OR) 3.10, 95% Confidence Interval (CI) [2.21-4.34]. Clinical severity at pre treatment was related to lower odds, OR 0.62, 95% CI [0.50-0.77], and 0.51, 95% CI [0.51-0.80], for treatment and control conditions. In terms of sociodemographic variables, being in a relationship, 0.58, 95% CI [0.35-0.95], having at least a university degree, 0.54, 95% CI [0.33-0.88], and being older, 0.78, 95% CI, [0.62-0.98], were also associated with lower odds of deterioration, but only for patients assigned to treatment. Conclusion: Deterioration among patients receiving ICBT is not uncommon and should be monitored by researchers in order to reverse a negative treatment trend.

  • 14.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Negative effects of Internet-based cognitive behavior therapy: Monitoring and reporting deterioration and adverse and unwanted events2016Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Internet-based cognitive behavior therapy (ICBT) has the potential of providing many patients with an effective form of psychological treatment. However, despite helping to improve mental health and well-being, far from everyone seem to benefit. In some cases, negative effects may also emerge. The overall aim of the present thesis was to establish the occurrence and characteristics of such incidents in ICBT using a combination of quantitative and qualitative methods. Study I determined deterioration, non-response, and adverse and unwanted events in a sample of 133 patients undergoing ICBT for social anxiety disorder. The results indicated that up to 6.8% fared worse during the treatment period, depending on the self-report measure and time point, as determined using the Reliable Change Index (RCI), while the non-response rate was between 29.3 to 86.5% at post treatment assessment, and 12.9% experienced other negative effects. Study II investigated the responses to open-ended questions on adverse and unwanted events among 556 patients in four separate clinical trials of ICBT; social anxiety disorder, panic disorder, major depressive disorder, and procrastination. In total, 9.3% reported negative effects, with a qualitative content analysis revealing two categories and four subcategories; patient-related, i.e., gaining insight and experiencing new symptoms, and treatment-related, i.e., difficulties applying the treatment interventions and problems related to the treatment format. Study III explored the number of patients achieving reliable deterioration, as determined using the RCI on the individual raw scores of 2866 patients from 29 clinical trials of ICBT. The results showed that the deterioration rate was higher among patients in a control condition, 17.4%, in comparison to treatment, 5.8%. Predictors were related to decreased odds of deterioration for patients receiving treatment; clinical severity at pre treatment assessment, being in a relationship, having a university degree, and being older. As for the control condition, only clinical severity at pre treatment assessment was associated with decreased odds of deterioration. Study IV examined a newly developed self-report measure for monitoring and reporting adverse and unwanted events, the Negative Effects Questionnaire. The results suggested a six-factor solution with 32 items; symptoms, quality, dependency, stigma, hopelessness, and failure. One-third of the patients reported experiencing unpleasant memories, stress, and anxiety, with novel symptoms and a lack of quality in the treatment and therapeutic relationship having the greatest negative impact. The general finding of the present thesis is that negative effects do occur in ICBT and that they are characterized by deterioration, non-response, and adverse and unwanted events, similar to psychological treatments delivered face-to-face. Researchers and clinicians in ICBT are recommended to monitor and report negative effects to prevent a negative treatment trend and further the understanding of what might contribute to their incidents. Future research should investigate the relationship between negative effects and treatment outcome, especially at follow-up, to examine if they are transient or enduring. Also, interviews could be conducted with those achieving reliable deterioration to explore if and how it is experienced by the patients and to see if it is attributed to the treatment interventions or other circumstances.

  • 15.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Negative effects of psychotherapy: Monitoring and reporting deterioration and adverse and unwanted events2017Conference paper (Other academic)
    Abstract [sv]

    Internetbaserad kognitiv beteendeterapi (IKBT) har goda förutsättningar att hjälpa människor övervinna psykisk ohälsa och förbättra sitt välmående. Trots detta är det långtifrån alla patienter som erfar en förbättring, vissa kan till och med försämras eller uppleva andra typer av negativa effekter. Aktuell presentation summerar resultatet från fyra studier inom ramen för en doktorsavhandling i psykologi som har undersökt förekomst och kännetecken av negativa effekter i IKBT. Kvantitativa och kvalitativa ansatser har använts för att utforska fenomenet bland cirka 3000 patienter. Sammanfattningsvis försämras 5,8 % av alla patienter som får IKBT, jämfört med 17,4 % i väntelista, där bland annat högre ålder, högre utbildningsnivå och att vara i ett förhållande minskar oddsen för försämring i IKBT. På öppna frågor rapporterar även 9,3 % av alla patienter nya symptom och problem att fullfölja behandlingsprogrammen som negativt. Ett nytt självskattningsformulär utvecklades för att lättare mäta dessa typer av negativa effekter, the Negative Effects Questionnaire, bestående av 32 items där faktorerna symptom och bristande kvalitet på behandlingen förklarade den största delen av variansen. Implikationerna av fynden kommer att diskuteras, liksom vikten av fortsatt forskning för att minska risken för negativa effekter inom IKBT samt kognitiv beteendeterapi.

  • 16.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Alhashwa, Peter
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Boettcher, Johanna
    Freie Universität Berlin.
    Andersson, Gerhard
    Linköping University and Karolinska Institutet.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Investigating the Impact of Negative Effects during a Smartphone-Based Treatment for Social Anxiety Disorder: A Correlational Study2015Conference paper (Refereed)
    Abstract [en]

    Negative effects of psychological treatments constitute an important but largely unexplored area of research. Prior investigations have indicated that approximately 5-10% of all patients receiving face-to-face treatments deteriorate. In addition, other types of negative effects could exist as well, for instance, novel symptoms, social stigma, and interpersonal difficulties, but have been studied to a lesser extent. Meanwhile, negative effects are also assumed to occur in psychological treatments delivered online, but their incidence and impact is still unknown. In the current study, data collected from a smartphone-based treatment for social anxiety disorder (total N =189) was assessed in order to determine the influence of negative effects on treatment outcome. A new self-report measure for reporting negative effects was developed through a comprehensive literature search and a review of similar instruments for face-to-face treatments, consisting of sixty items scored on a five-point Likert-scale. Change from pre- to post-treatment assessment on the Liebowitz Social Anxiety Scale was correlated with the frequency and impact of negative effects, indicating that the number of incidents, r = .175, and the degree to which the patient was affected by the negative effects, r = .192, were related to less change in symptom severity. However, no sociodemographic variables or degree of social anxiety at baseline had a relationship with negative effects during treatment. In terms of the most recurring types of negative effects, patients reported that they had a bad conscience about not conducting their assignments (Item 16), being stressed by the treatment schedule (Item 2), and feeling left out during treatment (Item 55).

  • 17.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, G.
    Boettcher, J.
    Ebert, D.
    Cuijpers, P.
    Knaevelsrud, C.
    Ljótsson, B.
    Kaldo, V.
    Titov, N.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Consensus Statement on Defining and Measuring Negative Effects of Internet Interventions2014In: Abstracts from the 44th Congress of the European Association for Behavioural & Cognitive Therapies, 2014Conference paper (Refereed)
    Abstract [en]

    Introduction: Internet interventions have a great potential for alleviating emotional distress and promoting mental health. A number of clinical trials have demonstrated their efficacy for several psychiatric conditions, and Internet interventions will likely become a common alternative to face-to-face treatments. Meanwhile, research has paid little attention to the potential negative effects associated with treatment, warranting further investigation of the possibility that some patients might deteriorate or experience adverse events. Evidence from face-to-face treatments suggests that negative effects afflict 5-10% of all patients undergoing treatment in terms of deterioration alone. However, there is currently a lack of consensus on how to define and measure negative effects in psychotherapy research in general, leaving researchers without practical guidelines for monitoring and reporting negative effects in clinical trials.

    Method: The current paper seeks to provide recommendations that could promote the study of negative effects in Internet interventions with the aim of increasing the knowledge of its occurrence and characteristics. Ten leading experts in the field of Internet interventions were invited to participate and share their perspective on how to explore negative effects, using the Delphi technique to facilitate a dialogue and reach an agreement.

    Results: The importance of conducting further research on negative effects is emphasized, and suggestions on how to classify and measure negative effects in Internet interventions are provided, involving methods from both quantitative and qualitative research. Potential mechanisms underlying negative effects are also presented, differentiating common factors shared with face-to-face treatments from those unique to treatments delivered via the Internet.

    Conclusion: Negative effects are to be expected and need to be acknowledged to a greater extent, advising researchers to systematically probe for negative effects whenever conducting clinical trials involving Internet interventions, as well as to share their findings in scientific journals.

  • 18.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Boettcher, Johanna
    Ebert, David Daniel
    Cuijpers, Pim
    Knaevelsrud, Christine
    Ljótsson, Brjánn
    Kaldo, Viktor
    Titov, Nickolai
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Consensus statement on defining and measuring negative effects of Internet interventions2014In: Internet Interventions, ISSN 2214-7829, Vol. 1, no 1, 12-19 p.Article in journal (Refereed)
    Abstract [en]

    Internet interventions have great potential for alleviating emotional distress, promoting mental health, and enhancing well-being. Numerous clinical trials have demonstrated their efficacy for a number of psychiatric conditions, and interventions delivered via the Internet will likely become a common alternative to face-to-face treatment. Meanwhile, research has paid little attention to the negative effects associated with treatment, warranting further investigation of the possibility that some patients might deteriorate or encounter adverse events despite receiving best available care. Evidence from research of face-to-face treatment suggests that negative effects afflict 5–10% of all patients undergoing treatment in terms of deterioration. However, there is currently a lack of consensus on how to define and measure negative effects in psychotherapy research in general, leaving researchers without practical guidelines for monitoring and reporting negative effects in clinical trials. The current paper therefore seeks to provide recommendations that could promote the study of negative effects in Internet interventions with the aim of increasing the knowledge of its occurrence and characteristics. Ten leading experts in the field of Internet interventions were invited to participate and share their perspective on how to explore negative effects, using the Delphi technique to facilitate a dialog and reach an agreement. The authors discuss the importance of conducting research on negative effects in order to further the understanding of its incidence and different features. Suggestions on how to classify and measure negative effects in Internet interventions are proposed, involving methods from both quantitative and qualitative research. Potential mechanisms underlying negative effects are also discussed, differentiating common factors shared with face-to-face treatments from those unique to treatments delivered via the Internet. The authors conclude that negative effects are to be expected and need to be acknowledged to a greater extent, advising researchers to systematically probe for negative effects whenever conducting clinical trials involving Internet interventions, as well as to share their findings in scientific journals.

  • 19.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Boettcher, Johanna
    Ebert, David Daniel
    Cuijpers, Pim
    Knaevelsrud, Christine
    Ljótsson, Brjánn
    Kaldo, Viktor
    Titov, Nickolai
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Consensus Statement on Defining and Measuring Negative Effects of Internet Interventions2014In: Oral Abstracts from the 7th Scientific Meeting of the International Society for Research on Internet Interventions, International Society for Research on Internet Interventions (ISRII) , 2014, 39-39 p.Conference paper (Refereed)
    Abstract [en]

    Purpose: Internet interventions provide a potential for promoting mental health and alleviating emotional distress. A large number of clinical trials have demonstrated their efficacy for several psychiatric conditions, and Internet interventions will likely become a common and valuable alternative within the regular health care. In the meantime, research has paid little attention to the possibility that some treatments might be associated with different types of negative effects. Evidence from face-to-face treatments suggests that 5-10% of all patients deteriorate despite receiving best available care. In addition, other forms of negative effects may exist as well, e.g., social stigmatization, interpersonal difficulties, and decreased self-esteem. However, a lack of agreement on how to define and measure negative effects has left researchers without practical guidelines for monitoring and reporting deterioration and adverse events in clinical trials, warranting a consensus for conducting research on negative effects.

    Method: The objective of the current paper is to provide recommendations that could promote the study of negative effects in Internet interventions. Ten leading experts in the field of Internet interventions were invited to participate and share their perspective on how to explore negative effects, using the Delphi technique to facilitate a dialogue and reach an agreement.

    Results: The importance of conducting further research on negative effects is discussed, and suggestions on how to classify and measure negative effects are provided, involving methods from quantitative and qualitative research. Potential mechanisms underlying negative effects are also presented, differentiating factors shared with face-to-face treatments from those unique to treatments delivered via the Internet.

    Conclusion: Negative effects should be expected and need to be recognized to a greater extent, and researchers are advised to systematically probe for negative effects whenever conducting clinical trials involving Internet interventions, as well as to share their findings in scientific journals.

  • 20.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Randomized Controlled Trial of Internet-Based Cognitive Behavior Therapy for Procrastination2014In: Abstracts from the 44th Congress of the European Association for Behavioural & Cognitive Therapies, The Hague: EABCT , 2014Conference paper (Refereed)
    Abstract [en]

    Introduction: Procrastination is a pervasive behavior pattern associated with psychological distress and decreased well-being. Approximately one-fifth of the adult population and half of the student population consider themselves having recurrent difficulties because of delaying their everyday tasks and commitments. Cognitive behavior therapy is regarded treatment of choice, and treatment interventions consisting of behavioral activation and exposure to discomfort are presumed suitable for managing procrastination. However, no randomized controlled trial has previously been performed, warranting further research on the efficacy of cognitive behavior therapy. Meanwhile, clinical trials of Internet-based cognitive behavior therapy has generated promising results in relation to a number of psychiatric conditions, but whether it may be used to alleviate problems of procrastination is still unclear. Method: Participants were recruited from advertisements in the media and on the Internet. One hundred and fifty participants with self-reported difficulties of procrastination were randomized into three conditions; guided self-help, self-help, or wait-lost control. The treatment consisted of ten modules delivered weekly during a ten week treatment period, involving psychoeducation and assignments specifically designed to target procrastination. Outcome measures concerning procrastination, depression, anxiety, and quality of life were distributed pre and post treatment.

    Results: Moderate to large effect sizes were found for both treatment conditions in terms of outcome measures on procrastination compared to wait-list control. No statistically significant difference were observed between the two treatment conditions, or any of the outcome measures of depression, anxiety, or quality of life. Results from follow-up will be available at the time of the conference.

    Conclusion: Participants receiving guided or unguided self-help improved on self-reported difficulties of procrastination, indicating that Internet-based cognitive behavior therapy may be beneficial for individuals suffering from procrastination. More research is however needed in order to determine its efficacy.

  • 21.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Boettcher, Johanna
    Andersson, Gerhard
    Schmidt, B.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Negative effects of Internet interventions: A qualitative content analysis of patients’ experiences with treatments delivered online2015Conference paper (Refereed)
    Abstract [en]

    Internet interventions have been shown to be a viable alternative to face-to-face treatments. However, not all patients benefit from such treatments, and it is possible that some may experience negative effects. The current study explored patients’ reported negative experiences while undergoing treatments delivered via the Internet. Data from four large clinical trials (total N = 558) revealed that 9.3% of patients encountered some type of negative effects. Qualitative content analysis was used to explore the patients’ responses to open-ended questions regarding their negative experiences. Results yielded two broad categories and four subcategories of negative effects: patient-related negative effects (insight and symptom) and treatment-related negative effects (implementation and format). Results emphasize the importance of always considering negative effects in Internet-based interventions, and point to several ways of preventing such experiences, including regular assessment of negative events, increasing the flexibility of treatment schedules and therapist contact, and prolonging the treatment duration.

  • 22.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Boettcher, Johanna
    Andersson, Gerhard
    Schmidt, Brad
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Negative Effects of Internet Interventions: A Qualitative Content Analysis of Patients' Experiences with Treatments Delivered Online2015In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 44, no 3, 223-236 p.Article in journal (Refereed)
    Abstract [en]

    Internet interventions are defined as the delivery of health care-related treatments via an online or a smartphone interface, and have been shown to be a viable alternative to face-to-face treatments. However, not all patients benefit from such treatments, and it is possible that some may experience negative effects. Investigations of face-to-face treatments indicate that deterioration occurs in 5-10% of all patients. The nature and scope of other negative effects of Internet interventions is, however, largely unknown. Hence, the current study explored patients' reported negative experiences while undergoing treatments delivered via the Internet. Data from four large clinical trials (total N=558) revealed that 9.3% of patients reported some type of negative effects. Qualitative content analysis was used to explore the patients' responses to open-ended questions regarding their negative experiences. Results yielded two broad categories and four subcategories of negative effects: patient-related negative effects (insight and symptom) and treatment-related negative effects (implementation and format). Results emphasize the importance of always considering negative effects in Internet-based interventions, and point to several ways of preventing such experiences, including regular assessment of negative events, increasing the flexibility of treatment schedules and therapist contact, as well as prolonging the treatment duration.

  • 23.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Boettcher, Johanna
    Andersson, Gerhard
    Linköping University & Karolinska Institutet.
    Schmidt, Brad
    Florida State University, Tallahassee, FL.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Negative Effects of Internet Interventions: A Qualitative Content Analysis of Patients’ Experiences with Treatments Delivered Online2015Conference paper (Refereed)
    Abstract [en]

    Internet interventions are defined as the delivery of health care-related treatments via an online or a smartphone interface, and have been shown to be a viable alternative to face-to-face treatments. However, not all patients benefit from such treatments, and it is possible that some may experience negative effects. Investigations of face-to-face treatments indicate that deterioration occurs in 5–10% of all patients. The nature and scope of other negative effects of Internet interventions is, however, largely unknown. Hence, the current study explored patients’ reported negative experiences while undergoing treatments delivered via the Internet. Data from four large clinical trials (total N = 558) revealed that 9.3% of patients reported some type of negative effects. Qualitative content analysis was used to explore the patients’ responses to open-ended questions regarding their negative experiences. Results yielded two broad categories and four subcategories of negative effects: patient-related negative effects (insight and symptom) and treatment-related negative effects (implementation and format). Results emphasize the importance of always considering negative effects in Internet-based interventions, and point to several ways of preventing such experiences, including regular assessment of negative events, increasing the flexibility of treatment schedules and therapist contact, as well as prolonging the treatment duration.

  • 24.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Understanding and Treating Procrastination: a Review of a Common Self-Regulatory Failure2014In: Psychology, ISSN 2152-7180, E-ISSN 2152-7199, Vol. 5, no 3, 1488-1502 p.Article in journal (Refereed)
    Abstract [en]

    Procrastination is a pervasive self-regulatory failure affecting approximately one-fifth of the adult population and half of the student population. It is defined as one’s voluntarily delay of an intended course of action despite being worse off as a result of that delay. Procrastination has a negative impact on performance and is associated with poorer mental health. Stress, worry, and feelings of guilt are common among those who procrastinate recurrently. In addition, procrastination is associated with fewer mental health-seeking behaviors and increased treatment delay, leading to greater distress and the exacerbation of illness. The current paper seeks to provide a theoretical and clinical understanding of procrastination by reviewing prior research. Procrastination can be understood using different motivational theories, learning theory, self-efficacy theory, as well as biases and heuristics. Temporal motivational theory is proposed as an integrated explanation for procrastination, consisting of the interaction of four different variables: expectancy, value, impulsiveness, and time, each of which affects the tendency to procrastinate. A general implication is that procrastination should be regarded as an idiosyncratic behavioral problem that requires a cognitive case conceptualization or a functional analysis in order to guide therapists in their work. A number of treatment interventions might be used in relation to procrastination—for example, efficacy performance spirals, automaticity, stimulus control, stimulus cues, learned industriousness, and cognitive restructuring. Furthermore, the current paper explores the evidence on using cognitive behavior therapy for procrastination, discussing the scarcity of randomized controlled trials and the lack of validated outcome measures, and highlighting the need for further research.

  • 25.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Internet-based cognitive behavior therapy for procrastination: study protocol for a randomized controlled trial2013In: JMIR Research Protocols, ISSN 1929-0748, Vol. 2, no 2, e46- p.Article in journal (Refereed)
    Abstract [en]

    Background: Procrastination, to voluntarily delay an intended course of action despite expecting to be worse-off for the delay, is a persistent behavior pattern that can cause major psychological suffering. Approximately half of the student population and 15%-20% of the adult population are presumed having substantial difficulties due to chronic and recurrent procrastination in their everyday life. However, preconceptions and a lack of knowledge restrict the availability of adequate care. Cognitive behavior therapy (CBT) is often considered treatment of choice, although no clinical trials have previously been carried out.

    Objective: The aim of this study will be to test the effects of CBT for procrastination, and to investigate whether it can be delivered via the Internet.

    Methods: Participants will be recruited through advertisements in newspapers, other media, and the Internet. Only people residing in Sweden with access to the Internet and suffering from procrastination will be included in the study. A randomized controlled trial with a sample size of 150 participants divided into three groups will be utilized. The treatment group will consist of 50 participants receiving a 10-week CBT intervention with weekly therapist contact. A second treatment group with 50 participants receiving the same treatment, but without therapist contact, will also be employed. The intervention being used for the current study is derived from a self-help book for procrastination written by one of the authors (AR). It includes several CBT techniques commonly used for the treatment of procrastination (eg, behavioral activation, behavioral experiments, stimulus control, and psychoeducation on motivation and different work methods). A control group consisting of 50 participants on a wait-list control will be used to evaluate the effects of the CBT intervention. For ethical reasons, the participants in the control group will gain access to the same intervention following the 10-week treatment period, albeit without therapist contact.

    Results: The current study is believed to result in three important findings. First, a CBT intervention is assumed to be beneficial for people suffering from problems caused by procrastination. Second, the degree of therapist contact will have a positive effect on treatment outcome as procrastination can be partially explained as a self-regulatory failure. Third, an Internet based CBT intervention is presumed to be an effective way to administer treatment for procrastination, which is considered highly important, as the availability of adequate care is limited. The current study is therefore believed to render significant knowledge on the treatment of procrastination, as well as providing support for the use of Internet based CBT for difficulties due to delayed tasks and commitments.

    Conclusions: To our knowledge, the current study is the first clinical trial to examine the effects of CBT for procrastination, and is assumed to render significant knowledge on the treatment of procrastination, as well as investigating whether it can be delivered via the Internet.

    Trial Registration: ClinicalTrials.gov: NCT01842945; http://clinicaltrials.gov/show/NCT01842945 (Archived by WebCite at http://www.webcitation.org/6KSmaXewC).

  • 26.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Internet-based cognitive behavior therapy for procrastination: A randomized controlled trial2015Conference paper (Refereed)
    Abstract [en]

    Procrastination is a common self-regulatory failure associated with personal distress, but research investigating different treatment interventions for the condition is scarce. In the current study, 150 participants were randomized into guided self help, unguided self-help, and wait-list control. Outcome measures were administered before and after the treatment, or weekly throughout the treatment period, and the intention-to-treat principle was used for all statistical analyses. Mixed effects models revealed moderate between-group effect sizes comparing guided and unguided self-help to wait-list control; the Pure Procrastination Scale (Cohen’s d = 0.70, 95% CI [0.29, 1.10], and d = 0.50, 95% CI [0.10, 0.90]), and the Irrational Procrastination Scale (d = 0.81 95% CI [0.40, 1.22], and d = 0.69 95% CI [0.29, 1.09]). Clinically significant change was achieved among 31.3-40.0% for guided self-help, compared to 24.0-36.0% for unguided self-help. Neither of the treatment conditions was found to be superior on any of the outcome measures.

  • 27.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Investigating the impact of negative effects during a smartphone-based treatment for social anxiety disorder: A correlational study2015Conference paper (Refereed)
    Abstract [en]

    Negative effects of treatments delivered online constitute an important but unexplored area of research. In the current study, data collected from a smartphone-based treatment for social anxiety disorder (total N =189) was assessed in order to determine the influence of negative effects on treatment outcome. A new self-report measure for reporting negative effects was developed, and the scores were correlated with the change from pre- to post-treatment assessment on the Liebowitz Social Anxiety Scale. The results indicate that the number of incidents, r = .175, and the degree to which the patient was affected by the negative effects, r = .192, were related to less change in symptom severity. In terms of the most recurring types of negative effects, patients reported that they had a bad conscience about not conducting their assignments (Item 16), being stressed by the treatment schedule (Item 2), and feeling left out during treatment (Item 55).

  • 28.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Negative effects of Internet interventions: A qualitative content analysis of patients' experiences with treatments delivered online2015Conference paper (Refereed)
    Abstract [en]

    Internet interventions have been shown to be a viable alternative to face-to-face treatments. However, not all patients benefit from such treatments, and it is possible that some may experience negative effects. The current study explored patients’ reported negative experiences while undergoing treatments delivered via the Internet. Data from four large clinical trials (total N = 558) revealed that 9.3% of patients encountered some type of negative effects. Qualitative content analysis was used to explore the patients’ responses to open-ended questions regarding their negative experiences. Results yielded two broad categories and four subcategories of negative effects: patient-related negative effects (insight and symptom) and treatment-related negative effects (implementation and format). Results emphasize the importance of always considering negative effects in Internet-based interventions, and point to several ways of preventing such experiences, including regular assessment of negative events, increasing the flexibility of treatment schedules and therapist contact, and prolonging the treatment duration.

  • 29.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Behandlingen av psykisk ohälsa måste regleras: DN Debatt 2017-07-222017In: Dagens Nyheter, ISSN 1101-2447Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    Psykologiska behandlingsmetoder är ofta kraftfulla nog att hjälpa människor. Samtidigt visar ny forskning att psykologisk behandling som utövas på fel sätt kan vara direkt skadlig. Det är hög tid att se över vem som egentligen får behandla psykisk ohälsa, skriver en expertgrupp legitimerade psykologer och psykoterapeuter.

  • 30.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Forsell, E.
    Svensson, A.
    Andersson, G.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Overcoming procrastination: One-year follow-up and predictors of change in a randomized controlled trial of Internet-based cognitive behavior therapy2016Conference paper (Refereed)
    Abstract [en]

    Aim: Procrastination refers to the purposeful delay of an intended course of action and can become a persistent behavioral pattern associated with reduced mood, increased stress, and poorer performance. One-fifth of the adult population and half of the student population experience significant difficulties due to procrastination, but has received little attention in clinical research. Meanwhile, Internet-based cognitive behavior therapy (ICBT) has been found promising for several conditions, but has not yet been used in relation to procrastination. The current study thus aimed to examine the efficacy of ICBT for procrastination at post treatment and one-year follow-up, as well as to investigate predictors of change.

    Method: Participants (N = 150) were randomized to a ten-week treatment programme; guided self-help, unguided self-help, and wait-list control (receiving unguided self-help after the first treatment period). Outcome measures were administered at screening, post treatment, one-year follow-up, or weekly, consisting of the Pure Procrastination Scale (PPS), the Irrational Procrastination Scale (IPS), the Susceptibility to Temptation Scale, the Montgomery Åsberg Depression Rating Scale, the Generalized Anxiety Disorder Assessment, and the Quality of Life Inventory. Intention-to-treat was used for all statistical analyses, with mixed-effects models to assess the effect of time and group.

    Results: Moderate to large effect sizes were obtained at post treatment comparing guided and unguided self-help with wait-list control, the PPS, Cohen’s d = 0.70, 95% confidence interval (CI) [0.29, 1.10], and d = 0.50, 95% CI [0.10, 0.90], and the IPS, d = 0.81 95% CI [0.40, 1.22], and d = 0.69 95% CI [0.29, 1.09]. Clinically significant change was achieved among 31.3–40.0% for guided self-help, compared with 24.0–36.0% for unguided self-help. Neither of the treatment conditions was found to be superior on any of the outcome measures, Fs (98, 65.17-72.55) < 1.70, p > .19. One-year follow-up data has just been collected and the results of will be available at the time of the conference, including predictors of change.

    Conclusion: ICBT could be useful for managing self-reported problems of procrastination, with results at one-year follow-up and predictors of change revealing the long-term benefit and possible variables responsible for a successful treatment outcome.

  • 31.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Forsell, E.
    Svensson, A.
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Understanding and treating procrastination2015Conference paper (Refereed)
    Abstract [sv]

    Prokrastinering definieras som beteendet att medvetet förhala ett tilltänkt handlingsförlopp, trots medvetenhet om att det kan medföra negativa konsekvenser. Utöver att påverka prestationen på en given uppgift eller aktivitet har prokrastinering även visat sig vara associerat med sämre psykisk och fysisk hälsa. Trots detta är forskning på effektiva behandlingsinterventioner för prokrastinering ytterst begränsat. Aktuellt symposium syftar till att delge resultaten från två kliniska studier där kognitiv beteendeterapi har använts i behandling av personer med svåra problem av prokrastinering, dels i form av Internetbaserad självhjälpsbehandling, dels i form av gruppbehandling. Utöver en presentation av utfallet ges dessutom en genomgång av en klusteranalys av de deltagare som har sökt hjälp för prokrastinering, vilken visar på behovet av noggrann screening och god differentialdiagnostik inför en behandling.

  • 32.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Forsell, Erik
    Svensson, Andreas
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Internet-based cognitive behavior therapy for procrastination: a randomized controlled trial2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 4, 808-824 p.Article in journal (Refereed)
    Abstract [en]

    Objective: Procrastination can be a persistent behavior pattern associated with personal distress. However, research investigating different treatment interventions is scarce, and no randomized controlled trial has examined the efficacy of cognitive−behavior therapy (CBT). Meanwhile, Internet-based CBT has been found promising for several conditions, but has not yet been used for procrastination. Method: Participants (N = 150) were randomized to guided self-help, unguided self-help, and wait-list control. Outcome measures were administered before and after treatment, or weekly throughout the treatment period. They included the Pure Procrastination Scale, the Irrational Procrastination Scale, the Susceptibility to Temptation Scale, the Montgomery Åsberg Depression Rating Scale−Self-report version, the Generalized Anxiety Disorder Assessment, and the Quality of Life Inventory. The intention-to-treat principle was used for all statistical analyses. Results: Mixed-effects models revealed moderate between-groups effect sizes comparing guided and unguided self-help with wait-list control; the Pure Procrastination Scale, Cohen’s d = 0.70, 95% confidence interval (CI) [0.29, 1.10], and d = 0.50, 95% CI [0.10, 0.90], and the Irrational Procrastination Scale, d = 0.81 95% CI [0.40, 1.22], and d = 0.69 95% CI [0.29, 1.09]. Clinically significant change was achieved among 31.3–40.0% for guided self-help, compared with 24.0–36.0% for unguided self-help. Neither of the treatment conditions was found to be superior on any of the outcome measures, Fs(98, 65.17−72.55)< 1.70, p >.19. Conclusion: Internet-based CBT could be useful for managing self-reported difficulties due to procrastination, both with and without the guidance of a therapist.

  • 33.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Forsell, Erik
    Svensson, Andreas
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Overcoming procrastination: one-year follow-up and predictors of change in a randomized controlled trial of Internet-based cognitive behavior therapy2017In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 46, no 3, 177-195 p.Article in journal (Refereed)
    Abstract [en]

    Procrastination is a common self-regulatory failure that can have a negative impact on well-being and performance. However, few clinical trials have been conducted, and no follow-up has ever been performed. The current study therefore aimed to provide evidence for the long-term benefits and investigate predictors of a positive treatment outcome among patients receiving Internet-based cognitive behavior therapy (ICBT). A total of 150 self-recruited participants were randomized to guided or unguided ICBT. Self-report measures of procrastination, depression, anxiety, and quality of life were distributed at pre-treatment assessment, post-treatment assessment, and one-year follow-up. Mixed effects models were used to investigate the long-term gains, and multiple linear regression for predictors of a positive treatment outcome, using the change score on the Irrational Procrastination Scale as the dependent variable. Intention-to-treat was implemented for all statistical analyses. Large within-group effect sizes for guided and unguided ICBT, Cohen’s d = .97–1.64, were found for self-report measures of procrastination, together with d = .56–.66 for depression and anxiety. Gains were maintained, and, in some cases, improved at follow-up. Guided and unguided ICBT did not differ from each other, mean differences −.31–1.17, 95% CIs [−2.59–3.22], and none of the predictors were associated with a better result, bs −1.45–1.61, 95% CIs [−3.14–4.26]. In sum, ICBT could be useful and beneficial in relation to managing procrastination, yielding great benefits up to one year after the treatment period has ended, with comparable results between guided and unguided ICBT.

  • 34.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Forsell, Erik
    Karolinska Institutet.
    Svensson, Andreas
    Linköping University.
    Andersson, Gerhard
    Linköping University.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Overcoming procrastination: One-year follow-up and predictors of change in a randomized controlled trial of Internet-based cognitive behavior therapy2016In: EABCT 2016 Abstract Book: Total Awareness, The European Association for Behavioural and Cognitive Therapies , 2016, 542-542 p.Conference paper (Refereed)
    Abstract [en]

    Introduction: Procrastination is defined as the voluntary delay of an intended course of action despite resulting in negative consequences. Procrastination can become a persistent behavioral pattern associated with reduced mood, increased stress, and poorer performance. Approximately one-fifth of the adult population and more than half of the student population experience significant difficulties due to procrastination. However, despite its prevalence, it has received little attention in clinical research. Meanwhile, Internet-based cognitive behavior therapy (ICBT) has been found promising for several psychiatric conditions, but has not yet been used in relation to procrastination. The current study thus aimed to examine the efficacy of ICBT for procrastination at post treatment and one-year follow-up. Furthermore, predictors of change were investigated in order to distinguish variables that might predict at positive treatment outcome.

    Method: Self-recruited participants (N = 150) with severe and chronic procrastination were randomized to a ten-week treatment program administered via the Internet; guided self-help, unguided self-help, and wait-list control (receiving unguided self-help after the first treatment period). Outcome measures were administered at screening, post treatment, one-year follow-up, or weekly; the Pure Procrastination Scale (PPS), the Irrational Procrastination Scale (IPS), the Susceptibility to Temptation Scale, the Montgomery Åsberg Depression Rating Scale, the Generalized Anxiety Disorder – 7 Items, and the Quality of Life Inventory. The intention-to-treat principle was used for all statistical analyses.

    Results: Moderate to large effect sizes were obtained at post treatment comparing guided and unguided self-help with wait-list control, the PPS, Cohen’s d = 0.70, 95% confidence interval (CI) [0.29, 1.10], and d = 0.50, 95% CI [0.10, 0.90], and the IPS, d = 0.81 95% CI [0.40, 1.22], and d = 0.69 95% CI [0.29, 1.09]. Clinically significant change was achieved among 31.3–40.0% for guided self-help, compared with 24.0–36.0% for unguided self-help. Neither of the treatment conditions were found to be superior on any of the outcome measures, Fs (98, 65.17-72.55) < 1.70, p > .19. In terms of the outcome at the one-year follow-up, the results will be available at the time of the conference, including the analyses of predictors of change.

    Conclusion: ICBT could be useful for managing self-reported problems of procrastination, with results from post treatment revealing that both guided self-help and unguided self-help can be of great aid. Findings from the one-year follow-up and analyses of predictors of change will help to determine the long-term benefit and the possible variables responsible for a successful treatment outcome.

  • 35.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Forsell, Erik
    Svensson, Andreas
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Differentiating Procrastinators from Each Other: A Cluster Analysis2015In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 44, no 6, 480-490 p.Article in journal (Refereed)
    Abstract [en]

    Procrastination refers to the tendency to postpone the initiation and completion of a given course of action. Approximately one-fifth of the adult population and half of the student population perceive themselves as being severe and chronic procrastinators. Albeit not a psychiatric diagnosis, procrastination has been shown to be associated with increased stress and anxiety, exacerbation of illness, and poorer performance in school and work. However, despite being severely debilitating, little is known about the population of procrastinators in terms of possible subgroups, and previous research has mainly investigated procrastination among university students. The current study examined data from a screening process recruiting participants to a randomized controlled trial of Internet-based cognitive behavior therapy for procrastination (Rozental et al., in press). In total, 710 treatment-seeking individuals completed self-report measures of procrastination, depression, anxiety, and quality of life. The results suggest that there might exist five separate subgroups, or clusters, of procrastinators: “Mild procrastinators” (24.93%), “Average procrastinators” (27.89%), “Well-adjusted procrastinators” (13.94%), “Severe procrastinators” (21.69%), and “Primarily depressed” (11.55%). Hence, there seems to be marked differences among procrastinators in terms of levels of severity, as well as a possible subgroup for which procrastinatory problems are primarily related to depression. Tailoring the treatment interventions to the specific procrastination profile of the individual could thus become important, as well as screening for comorbid psychiatric diagnoses in order to target difficulties associated with, for instance, depression.

  • 36.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Forsell, Erik
    Svensson, Andreas
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Psychometric evaluation of the Swedish version of the pure procrastination scale, the irrational procrastination scale, and the susceptibility to temptation scale in a clinical population2014In: BMC Psychology, E-ISSN 2050-7283, Vol. 2, 54Article in journal (Refereed)
    Abstract [en]

    Background: Procrastination is a prevalent self-regulatory failure associated with stress and anxiety, decreased well-being, and poorer performance in school as well as work. One-fifth of the adult population and half of the student population describe themselves as chronic and severe procrastinators. However, despite the fact that it can become a debilitating condition, valid and reliable self-report measures for assessing the occurrence and severity of procrastination are lacking, particularly for use in a clinical context. The current study explored the usefulness of the Swedish version of three Internet-administered self-report measures for evaluating procrastination; the Pure Procrastination Scale, the Irrational Procrastination Scale, and the Susceptibility to Temptation Scale, all having good psychometric properties in English.

    Methods: In total, 710 participants were recruited for a clinical trial of Internet-based cognitive behavior therapy for procrastination. All of the participants completed the scales as well as self-report measures of depression, anxiety, and quality of life. Principal Component Analysis was performed to assess the factor validity of the scales, and internal consistency and correlations between the scales were also determined. Intraclass Correlation Coefficient, Minimal Detectable Change, and Standard Error of Measurement were calculated for the Irrational Procrastination Scale.

    Results: The Swedish version of the scales have a similar factor structure as the English version, generated good internal consistencies, with Cronbach’s α ranging between .76 to .87, and were moderately to highly intercorrelated. The Irrational Procrastination Scale had an Intraclass Correlation Coefficient of .83, indicating excellent reliability. Furthermore, Standard Error of Measurement was 1.61, and Minimal Detectable Change was 4.47, suggesting that a change of almost five points on the scale is necessary to determine a reliable change in self-reported procrastination severity.

    Conclusions: The current study revealed that the Pure Procrastination Scale, the Irrational Procrastination Scale, and the Susceptibility to Temptation Scale are both valid and reliable from a psychometric perspective, and that they might be used for assessing the occurrence and severity of procrastination via the Internet.

  • 37.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Almquist Tangen, Josefine
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Experiences of undergoing Internet-based cognitive behavior therapy for procrastination: A qualitative study2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 3, 314-322 p.Article in journal (Refereed)
    Abstract [en]

    Internet interventions constitute a promising and cost-effective treatment alternative for a wide range of psychiatric disorders and somatic conditions. Several clinical trials have provided evidence for its efficacy and effectiveness, and recent research also indicate that it can be helpful in the treatment of conditions that are debilitating, but do not necessarily warrant more immediate care, for instance, procrastination, a self-regulatory failure that is associated with decreased well-being and mental health. However, providing treatment interventions for procrastination via the Internet is a novel approach, making it unclear how the participants themselves perceive their experiences. The current study thus investigated participants' own apprehension of undergoing Internet-based cognitive behavior therapy for procrastination by distributing open-ended questions at the post-treatment assessment, for instance, “What did you think about the readability of the texts”, “How valuable do you believe that this treatment has been for you?”, and “The thing that I am most displeased with (and how it could be improved) is …”. In total, 75 participants (50%) responded, and the material was examined using thematic analysis. The results indicate that there exist both positive and negative aspects of the treatment program. Many participants increased their self-efficacy and were able to gain momentum on many tasks and assignments that had been deferred in their everyday life. Meanwhile, several participants lacked motivation to complete the exercises, had too many conflicting commitments, and were unable to keep up with the tight treatment schedule. Hence, the results suggest that Internet interventions for procrastination could profit from individual tailoring, shorter and more manageable modules, and that the content need to be adapted to the reading comprehension and motivational level of the participant.

  • 38.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Lindner, Philip
    Nilsson, Simon
    Mårtensson, Lina
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Treating Procrastination using Cognitive Behavior Therapy: A Pragmatic Randomized Controlled Trial Comparing Treatment Delivered via the Internet or in Groups2017In: BABCP Manchester 2017: Abstract Book, 2017, 60-60 p.Conference paper (Refereed)
    Abstract [en]

    Procrastination is a common problem among university students, with at least half of the population reporting great difficulties initiating or completing certain tasks and assignments. Procrastination can have a negative impact on course grades and the ability to achieve a university degree, but can also lead to psychological distress, such as, stress and anxiety. Cognitive Behavior Therapy (CBT) is often considered treatment of choice, but few studies have investigated its effectiveness in regular clinical settings.

    The current study explored its treatment effects using a pragmatic randomized controlled trial comparing treatment delivered during eight weeks as unguided self-help via the Internet (ICBT) or as group CBT. In total, 92 university students with severe procrastination were included in the study (registered as a clinical trial on Clinicaltrials.gov: NCT02112383). Outcome measures included self-reported procrastination, depression, anxiety, and physical and psychological well-being, which were distributed at pre- and posttreatment, as well as six-month follow-up. An outcome measure of procrastination was also administered weekly. Linear mixed and fixed effects models were calculated, along with improvement and deterioration rates.

    The results showed that both unguided ICBT and group CBT yielded large within-group effect sizes on procrastination, Cohen's d = 1.24- 1.29, 95% Confidence Interval (CI) [0.76- 1.74], and small to moderate benefits for depression, anxiety, and well-being, d = 0.37-0.68, 95% CI [-0.06-1.12]. In total, 32.6% were improved at post-treatment and 45.6% at follow- up. No differences between conditions were observed directly after the treatment period, however, participants in group CBT continued or maintained their improvement at follow- up, while participants in unguided ICBT showed signs of deterioration. The findings from the current study suggest that CBT might be an effective treatment for students with problems of procrastination, but that a group format may be better for some in order to sustain their benefits over time. Procrastination is a common problem among university students, but few clinical trials have investigated the efficacy of different treatment interventions for this condition. The current study compared the results of CBT delivered as an unguided Internet-based treatment and CBT distributed in groups. The findings suggest that a both formats is beneficial for many individuals with difficulties of procrastination, but that group CBT could be better for some, at least in the long-run. Together with a previous randomised controlled trial of CBT for procrastination evidence now looks promising with regard to providing effective treatments for this condition, but more research is warranted in terms of improving the results and to evaluate the benefits using also behavioural measures.

  • 39.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Nilsson, Sam
    Karolinska Institutet.
    Rizzo, Angela
    Karolinska Institutet.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Group versus Internet-based cognitive-behavioral therapy for procrastination: study protocol for a randomized controlled trial.2014In: Internet Interventions, ISSN 2214-7829, Vol. 1, no 2, 84-89 p.Article in journal (Refereed)
    Abstract [en]

    Procrastination is defined as a voluntarily delay of an intended course of action despite expecting to be worse-off for the delay, and is considered a persistent behavior pattern that can result in major psychological suffering. About one-fifth of the adult population and half of the student population are presumed having substantial difficulties due to recurrent procrastination in their everyday lives. However, chronic and severe procrastinators seldom receive adequate care due to preconceptions and the lack of understanding regarding procrastination and the treatment interventions that are assumed beneficial. Cognitive-behavioral therapy is often deemed a treatment of choice, although the evidence supporting its use is scarce, and only one randomized controlled trial has been performed. The primary aim of the proposed study is therefore to test the efficacy of cognitive-behavioral therapy delivered as either a group intervention or via the Internet. Participants will consist of students recruited through the Student Health Centre at Karolinska Institutet. A randomized controlled trial with a sample size of 100 participants divided into blocks of thirty will be used, comparing an eight-week Internet-based cognitive-behavioral therapy intervention, and an eight-week group cognitive-behavioral therapy based intervention. It is believed that the proposed study will result in two important findings. First, different treatment interventions in cognitive-behavioral therapy are assumed to be helpful for people suffering from problems caused by procrastination. Second, both an Internet-based cognitive-behavioral therapy intervention and a group intervention are presumed suitable for administering treatment for procrastination, which is considered important as the availability of adequate care is limited, particularly among students. The proposed study will increase the knowledge regarding the efficacy of different treatments of procrastination, as well as enhance the overall comprehension of the difficulties related to dilatory behavior.

  • 40.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Kottorp, Anders
    Boettcher, Johanna
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Negative Effects of Psychological Treatments: An Exploratory Factor Analysis of the Negative Effects Questionnaire for Monitoring and Reporting Adverse and Unwanted Events2016In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 6, e0157503Article in journal (Refereed)
    Abstract [en]

    Research conducted during the last decades has provided increasing evidence for the use of psychological treatments for a number of psychiatric disorders and somatic complaints. However, by focusing only on the positive outcomes, less attention has been given to the potential of negative effects. Despite indications of deterioration and other adverse and unwanted events during treatment, little is known about their occurrence and characteristics. Hence, in order to facilitate research of negative effects, a new instrument for monitoring and reporting their incidence and impact was developed using a consensus among researchers, self-reports by patients, and a literature review: the Negative Effects Questionnaire. Participants were recruited via a smartphone-delivered self-help treatment for social anxiety disorder and through the media (N = 653). An exploratory factor analysis was performed, resulting in a six-factor solution with 32 items, accounting for 57.64% of the variance. The derived factors were: symptoms, quality, dependency, stigma, hopelessness, and failure. Items related to unpleasant memories, stress, and anxiety were experienced by more than one-third of the participants. Further, increased or novel symptoms, as well as lack of quality in the treatment and therapeutic relationship rendered the highest self-reported negative impact. In addition, the findings were discussed in relation to prior research and other similar instruments of adverse and unwanted events, giving credence to the items that are included. The instrument is presently available in eleven different languages and can be freely downloaded and used from www.neqscale.com.

  • 41.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Kottorp, Anders
    University of Illinois at Chicago.
    Boettcher, Johanna
    Freie Universität Berlin.
    Andersson, Gerhard
    Linköping University.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Negative effects of psychological treatments: An exploratory factor analysis of the Negative Effects Questionnaire for monitoring and reporting adverse and unwanted events2016In: EABCT 2016 Abstract Book: Total Awareness, The European Association for Behavioural and Cognitive Therapies , 2016, 284-284 p.Conference paper (Refereed)
    Abstract [en]

    Research conducted during the last decades has provided increasing evidence for the use of psychological treatments for a number of psychiatric disorders and somatic complaints. However, by focusing only on the positive outcomes, less attention has been given to the potential of negative effects. Despite indications of deterioration and other adverse and unwanted events during treatment, little is known about their occurrence and characteristics. Hence, in order to facilitate research of negative effects, a new instrument for monitoring and reporting their incidence and impact was developed using a consensus among researchers, self-reports by patients, and a literature review: the Negative Effects Questionnaire. Participants were recruited via a smartphone-delivered self-help treatment for social anxiety disorder and through the media (N = 653). An exploratory factor analysis was performed, resulting in a six-factor solution with 32 items, accounting for 57.64% of the variance. The derived factors were: symptoms, quality, dependency, stigma, hopelessness, and failure. Items related to unpleasant memories, stress, and anxiety were experienced by more than one-third of the participants. Further, increased or novel symptoms, as well as lack of quality in the treatment and therapeutic relationship rendered the highest self-reported negative impact. In addition, the findings were discussed in relation to prior research and other similar instruments of adverse and unwanted events, giving credence to the items that are included. The instrument is presently available in eleven different languages and can be freely downloaded and used.

  • 42.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Kottorp, Anders
    Boettcher, Johanna
    Andersson, Gerhard
    Carlbring, Per
    Negative effects of psychological treatments: An exploratory factor analysis of the Negative Effects Questionnaire for monitoring and reporting adverse and unwanted events2017Conference paper (Refereed)
    Abstract [en]

    Research conducted during the last decades has provided increasing evidence for the use of psychological treatments for a number of psychiatric disorders and somatic complaints. However, by focusing only on the positive outcomes, less attention has been given to the potential of negative effects. Despite indications of deterioration and other adverse and unwanted events during treatment, little is known about their occurrence and characteristics. Hence, in order to facilitate research of negative effects, a new instrument for monitoring and reporting their incidence and impact was developed using a consensus among researchers, self-reports by patients, and a literature review: the Negative Effects Questionnaire. Participants were recruited via a smartphone-delivered self-help treatment for social anxiety disorder and through the media (N = 653). An exploratory factor analysis was performed, resulting in a six-factor solution with 32 items, accounting for 57.64% of the variance. The derived factors were: symptoms, quality, dependency, stigma, hopelessness, and failure. Items related to unpleasant memories, stress, and anxiety were experienced by more than one-third of the participants. Further, increased or novel symptoms, as well as lack of quality in the treatment and therapeutic relationship rendered the highest selfreported negative impact. In addition, the findings were discussed in relation to prior research and other similar instruments of adverse and unwanted events, giving credence to the items that are included. The instrument is presently available in eleven different languages and can be freely downloaded and used from www.neqscale.com.

  • 43.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Magnusson, K.
    Boettcher, J.
    Andersson, G.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    For better or worse: An individual patient data meta-analysis of deterioration among participants receiving Internet-based cognitive behavior therapy2016Conference paper (Refereed)
    Abstract [en]

    Aim: During the last couple of decades research on the efficacy and effectiveness of psychological treatments has provided evidence for its use in alleviating mental distress and enhancing well-being. Meanwhile, novel ways of delivering evidence-based methods, such as, via the Internet or smartphone applications, have received increasing support, with the potential of becoming an important and widely used addition to the health care system. Internet-based cognitive behavior therapy (ICBT) has for instance been shown to be beneficial in relation to a number of psychiatric and somatic disorders. However, research has almost solely focused on the positive results, neglecting the fact that psychological treatments also might have negative effects. Investigations from face-to-face settings have found that 5-10% of all patients deteriorate, but whether this is true for ICBT has been unclear. Hence, in order to examine deterioration in cognitive behavior therapy delivered via the Internet, an individual patient data meta-analysis was performed.

    Method: Patient-level data from 29 clinical trials of ICBT for depression, anxiety disorders, and other problems, e.g., pathological gambling and erectile dysfunction, were aggregated, totaling 2866 participants receiving either a treatment or control condition. Deterioration was assessed using the Reliable Change Index on each of the primary outcome measures. Participants identified as having deteriorated were subsequently analyzed using logistic regression to find potential predictors of a negative treatment outcome.

    Results: Using only available data, a total of 89 participants (3.1%) were recognized as having reliably deteriorated from pre to post treatment assessment, with an additional 17 participants (0.6%) from pre treatment to follow-up assessment. In general, more participants (N = 56) diagnosed with an anxiety disorder deteriorated, compared to depression (N = 16), and other problems (N = 30). Results using imputed values for missing data and an exploration of predictors of deterioration will be available at the time of the conference.

    Conclusion: Preliminary evidence indicates that deterioration among participants receiving ICBT afflicts approximately 3.1%, with higher rates for anxiety disorders than depression and other problems. A closer inspection could reveal potential predictors for deterioration, which, in turn, might be used to prevent or reverse a negative treatment outcome.

  • 44.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Magnusson, K.
    Boettcher, J.
    Andersson, G.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    For better or worse: An individual patient data meta-analysis of deterioration among participants receiving Internet-based cognitive behavior therapy2016Conference paper (Refereed)
    Abstract [en]

    Internet-based cognitive behavior therapy (ICBT) has shown promising results in relation to treating many psychiatric disorders. However, research on the potential for negative effects of their use has been lacking. An individual patient data meta-analysis of 29 clinical trials of ICBT (N = 2866) was thus performed using the Reliable Change Index for each primary outcome measures to distinguish deterioration rates among patients in treatment and control conditions. Statistical analyses of predictors were conducted using generalized linear mixed models and binomial logistic regression. Missing data was handled by multiple imputation. Deterioration rates were 122 (5.8%) in treatment and 130 (17.4%) in control conditions. Relative to receiving treatment, patients in a control condition had higher odds of deteriorating, Odds Ratios (OR) 3.10, 95% Confidence Interval (CI) [2.21, 4.34]. Clinical severity at pre treatment was related to lower odds, OR 0.62, 95% CI [0.50, 0.77], and 0.51, 95% CI [0.51, 0.80], for treatment and control conditions. In terms of sociodemographic variables, being in a relationship, 0.58, 95% CI [0.35, 0.95], having at least a university degree, 0.54, 95% CI [0.33, 0.88], and being older, 0.78, 95% CI, [0.62, 0.98], were also associated with lower odds of deterioration, but only for patients in a treatment condition. In sum, deterioration among patients receiving ICBT or being in a control condition can occur and should be monitored by researchers in order to reverse and prevent a negative treatment trend.

  • 45.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Magnusson, Kristoffer
    Boettcher, Johanna
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    For Better or Worse: An Individual Patient Data Meta-Analysis of Deterioration Among Participants Receiving Internet-Based Cognitive Behavior Therapy2017In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 85, no 2, 160-177 p.Article in journal (Refereed)
    Abstract [en]

    Objective: Psychological treatments can relieve mental distress and improve well-being, and the dissemination of evidence-based methods can help patients gain access to the right type of aid. Meanwhile, Internet-based cognitive–behavioral therapy (ICBT) has shown promising results for many psychiatric disorders. However, research on the potential for negative effects of psychological treatments has been lacking. Method: An individual patient data meta-analysis of 29 clinical trials of ICBT (N = 2,866) was performed using the Reliable Change Index for each primary outcome measures to distinguish deterioration rates among patients in treatment and control conditions. Statistical analyses of predictors were conducted using generalized linear mixed models. Missing data was handled by multiple imputation. Results: Deterioration rates were 122 (5.8%) in treatment and 130 (17.4%) in control conditions. Relative to receiving treatment, patients in a control condition had higher odds of deteriorating, odds ratios (ORs) = 3.10, 95% confidence interval (CI) [2.21, 4.34]. Clinical severity at pretreatment was related to lower odds, OR = 0.62, 95% CI [0.50, 0.77], and OR = 0.51, 95% CI [0.51, 0.80], for treatment and control conditions. In terms of sociodemographic variables, being in a relationship, OR = 0.58, 95% CI [0.35, 0.95], having at least a university degree, OR = 0.54, 95% CI [0.33, 0.88], and being older, OR = 0.78, 95% CI, [0.62, 0.98], were also associated with lower odds of deterioration, but only for patients assigned to a treatment condition. Conclusion: Deterioration among patients receiving ICBT or being in a control condition can occur and should be monitored by researchers to reverse and prevent a negative treatment trend.

  • 46.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Magnusson, Kristoffer
    Boettcher, Johanna
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    For Better or Worse: An Individual Patient Data Meta-analysis of Deterioration Among Participants Receiving Internet-based Cognitive Behavior Therapy2017Conference paper (Refereed)
    Abstract [en]

    Objective: Psychological treatments can relieve mental distress and improve well-being, and the dissemination of evidence-based methods can help patients gain access to the right type of aid. Meanwhile, Internet-based cognitive behavior therapy (ICBT) has shown promising results for many psychiatric disorders. However, research on the potential for negative effects of psychological treatments has been lacking. Method: An individual patient data meta-analysis of 29 clinical trials of ICBT (N = 2866) was performed using the Reliable Change Index for each primary outcome measures to distinguish deterioration rates among patients in treatment and control conditions. Statistical analyses of predictors were conducted using generalized linear mixed models. Missing data was handled by multiple imputation. Results: Deterioration rates were 122 (5.8%) in treatment and 130 (17.4%) in control conditions. Relative to receiving treatment, patients in a control condition had higher odds of deteriorating, Odds Ratios (OR) 3.10, 95% Confidence Interval (CI) [2.21-4.34]. Clinical severity at pre treatment was related to lower odds, OR 0.62, 95% CI [0.50-0.77], and 0.51, 95% CI [0.51-0.80], for treatment and control conditions. In terms of sociodemographic variables, being in a relationship, 0.58, 95% CI [0.35-0.95], having at least a university degree, 0.54, 95% CI [0.33-0.88], and being older, 0.78, 95% CI, [0.62-0.98], were also associated with lower odds of deterioration, but only for patients assigned to a treatment condition. Conclusion: Deterioration among patients receiving ICBT or being in a control condition can occur and should be monitored by researchers in order to reverse and prevent a negative treatment trend.

  • 47.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Magnusson, Kristoffer
    Boettcher, Johanna
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    For better or worse: An individual patient data meta-analysis of deterioration among participants receiving Internet-based cognitive behavior therapy2017In: BABCP Manchester 2017: Abstract Book, 2017, 119-120 p.Conference paper (Refereed)
    Abstract [en]

    Psychological treatments can relieve mental distress and improve well-being, and the dissemination of evidence-based methods can help patients gain access to the right type of aid. Meanwhile, Internet-based cognitive behavior therapy (ICBT) has shown promising results for many psychiatric disorders. However, research on the potential for negative effects of psychological treatments has been lacking. 

    An individual patient data meta-analysis of 29 clinical trials of ICBT (N = 2866) was performed using the Reliable Change Index for each primary outcome measures to distinguish deterioration rates among patients in treatment and control conditions. Statistical analyses of predictors were conducted using generalized linear mixed models. Missing data was handled by multiple imputation.

    Deterioration rates were 122 (5.8%) in treatment and 130 (17.4%) in control conditions. Relative to receiving treatment, patients in a control condition had higher odds of deteriorating, Odds Ratios (OR) 3.10, 95% Confidence Interval (CI) [2.21-4.34]. Clinical severity at pre treatment was related to lower odds, OR 0.62, 95% CI [0.50-0.77], and 0.51, 95% CI [0.51-0.80], for treatment and control conditions. In terms of sociodemographic variables, being in a relationship, 0.58, 95% CI [0.35-0.95], having at least a university degree, 0.54, 95% CI [0.33-0.88], and being older, 0.78, 95% CI, [0.62-0.98], were also associated with lower odds of deterioration, but only for patients assigned to a treatment condition.

    Deterioration among patients receiving ICBT or being in a control condition can occur and should be monitored by researchers in order to reverse and prevent a negative treatment trend.

    Negative effects of psychological treatments is largely unknown for many researchers and clinicians. However, evidence suggest that 5-10% of all patients deteriorate during treatment and that some also experience other adverse and unwanted events. The results from the current study indicate that deterioration occurs among some patients receiving cognitive behaviour therapy via the Internet. Furthermore, certain sociodemographic variables seem to be associated with lower odds of deterioration; older age, higher educational level, being in a relationship, and having higher symptom severity at pre treatment assessment. In addition, proportionally more patients deteriorated while in wait- list control, suggesting that a better match between patient and treatment format may be required, and that there are ethical and methodological issues surrounding the use of waitings periods in randomised controlled trials.

  • 48.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Malmquist, Anna
    Vulnerability and Acceptance: lesbian Women's Family-Making through Assisted Reproduction in Swedish Public Health Care2015In: Journal of GLBT Family Studies, ISSN 1550-428X, E-ISSN 1550-4298, Vol. 11, no 2, 127-150 p.Article in journal (Refereed)
    Abstract [en]

    Female same-sex couples in Sweden have had access to fertility treatment within public health care since 2005. Treatment is generally tax funded, with a minimal of personal expenses. After birth, both mothers gain legal status as the child's parents. This article draws on findings from interviews with 29 lesbian mothers, all of whom have sought treatment at fertility clinics within the Swedish public health care system. Parts of the interviews in which the mothers describe deficiencies in the provided treatment have been scrutinized in detail. Results show how heteronormative assumptions about the family and a feeling of exposure in the role of patient give rise to vulnerability in lesbian mothers. Furthermore, neither routines nor the offered treatment are adapted to lesbian women's specific needs. Regarding dealing with deficiencies, the interviews are filled with expressions of acceptance, which rhetorically minimize the impact of potential stressors. A main conclusion is that legal inclusion of lesbians in fertility treatment is of groundbreaking importance to lesbians with a desire to become parents. The next step is to address heteronormativity within the health care institutions in order to develop treatment adapted to lesbian couples’ specific needs.

  • 49.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Shafran, Roz
    Wade, Tracey
    Egan, Sarah
    Bergman Nordgren, Lise
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Landström, Andreas
    Roos, Stina
    Skoglund, Malin
    Thelander, Elisabet
    Trosell, Linnéa
    Örtenholm, Alexander
    Andersson, Gerhard
    A randomized controlled trial of Internet-Based Cognitive Behavior Therapy for perfectionism including an investigation of outcome predictors2017In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 95, 79-86 p.Article in journal (Refereed)
    Abstract [en]

    Being highly attentive to details can be a positive feature. However, for some individuals, perfectionism can lead to distress and is associated with many psychiatric disorders. Cognitive behavior therapy has been shown to yield many benefits for those experiencing problems with perfectionism, but the access to evidence-based care is limited. The current study investigated the efficacy of guided Internet-based Cognitive Behavior Therapy (ICBT) and predictors of treatment outcome. In total, 156 individuals were included and randomized to an eight-week treatment or wait-list control. Self-report measures of perfectionism, depression, anxiety, self-criticism, self-compassion, and quality of life were distributed during screening and at post-treatment. Intention-to-treat were used for all statistical analyses. Moderate to large between-group effect sizes were obtained for the primary outcome measures, Frost Multidimensional Perfectionism Scale, subscales Concerns over Mistakes and Personal Standards, Cohen's d = 0.68–1.00, 95% Confidence Interval (CI) [0.36–1.33], with 35 (44.9%) of the patients in treatment being improved. Predictors were also explored, but none were related to treatment outcome. In sum, guided ICBT can be helpful for addressing problems with clinical perfectionism, but research of its long-term benefits is warranted.

  • 50.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Wennersten, Lina
    Dansa på deadline: Uppskjutandets psykologi2014Book (Other academic)
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