To Örebro University

A large body of research identifies therapist expressed empathy as one of the most important predictors of psychotherapy outcome. Deliberate practice (DP) is an effective method to improve skills in many fields. We asked if DP also can be used to enhance the skill of expressing empathy.

Objective: The aim was to compare the efficacy of DP to didactical learning methods (DLM) in enhancing the skill of empathic expression in students.

Method: A repeated measures randomized controlled group design was used. Novice students (N = 36) from psychologist-, medicine-, social work-, and nursing programs received two training sessions of either DP (n = 21) or DLM (n = 15). Participants' skills in empathic expression were assessed with the Measure of Expressed Empathy (MEE) on three occasions: before the first, between, and after the last training session.

Results: Participants in the DP-group showed improved empathic expression, whereas participants in the DLM-group did not.

Conclusions: These findings suggest that DP is an effective training method for therapeutic skills such as empathic expression and holds implications for the future development of educational practices to incorporate active skill training methods.

BACKGROUND: Insomnia is a common and distressing disorder. Evidence suggests that metacognitive beliefs and maladaptive strategies, such as worry and rumination, may maintain insomnia.

OBJECTIVES: This study is the first trial of metacognitive therapy (MCT) for insomnia. It aimed to evaluate the effects of MCT on insomnia severity and examine how cognitive-attentional syndrome (CAS) components predict these changes.

METHODS: An uncontrolled open cohort trial was conducted with 31 participants in a clinic setting. Participants received up to ten MCT sessions and completed weekly measures of insomnia severity, anxiety, depressive symptoms, and metacognitive beliefs, including maladaptive strategies. The primary outcome was remission status from pre-to post-treatment. Associations between components of the cognitive-attentional syndrome (CAS) and insomnia severity were examined using a mixed model. Follow-up data were collected at 3, 6, and 12 months.

RESULTS: At post-treatment, 57 % of participants met remission criteria and 67 % scored below the clinical cut-off. Within-group effect sizes were large for the Insomnia Severity Index (Hedges' g = 1.64) and moderate for anxiety (HADS-A, g = 0.67) and depression (HADS-D, g = 0.72). Among those providing follow-up data, 87.5 % remained at or further improved their insomnia symptoms by their last assessment. Moreover, both between-person averages and within-person changes in maladaptive CAS strategies significantly predicted ISI scores, whereas only within-person changes in CAS-negative metacognitions reached significance.

CONCLUSIONS: These preliminary findings indicate that metacognitive therapy (MCT) shows promise as an intervention for insomnia. However, large-scale, controlled trials are necessary to further evaluate its clinical utility for this condition.

Background: Previous reports have highlighted the abundance of cognitive constructs in insomnia research as a growing issue. Several questionnaires that measure sleep-related cognitions have been developed and there are indications of conceptual overlap between different cognitive constructs and the questions used to operationalize them.

Objectives: This study examines the convergent validity of three established questionnaires measuring cognitive processes in insomnia: the Anxiety and Preoccupation about Sleep Questionnaire (APSQ), the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-10), and the Pre-Sleep Arousal Scale (PSAS-C). Another objective was to explore how a briefer scale can be structured as well as to investigate this scale's ability to predict incident and persistent insomnia compared to the established scales.

Methods: 2333 participants from the general population completed surveys on insomnia symptoms and cognitive processes at baseline and 18 months later. Confirmatory factor analysis was used to investigate the scales' conceptual overlap as well as distinctive factors. An exploratory factor analysis was conducted to investigate the underlying factor structure of the items from the APSQ, the DBAS-10 and the PSAS-C. This analysis formed the basis of the creation of a new short scale: Sleep Worry 7. Binary logistic regressions were used to assess all scales' abilities to predict incident and persistent insomnia.

Results and conclusions: The overlap between the three scales was neither large enough to conclude that they are measuring the same construct, nor could it be confirmed that they measure three distinct questionnaire-specific cognitive processes within insomnia. The brief scale created within this study was able to predict persistent insomnia at similar levels to the three established scales combined, indicating that it captures important cognitions involved in the maintenance of insomnia. Measuring sleep-related cognitions with fewer items might be beneficial in both clinical contexts and research.

Introduction: The Cognitive Model of Insomnia by Harvey has gained widespread recognition since 2002 and stimulated treatment development. In short, the model describes how excessive mental focus on sleep creates vicious cycles which maintain insomnia. Little is known about how the model might fit other sleep diagnoses, although the processes are applicable to other somatic disorders such as chronic pain and IBS. The aim of this study was to investigate the degree of insomnia-related processes in other sleep disorders.

Method: Participants (n = 2370) from a randomly selected sample of the general population completed a survey that included five psychological processes as outlined by Harvey (2002): unhelpful beliefs about sleep, monitoring for sleep-related threats, sleep-related safety behaviours, pre-sleep somatic arousal, and sleep-related worry. The following sleep disorders were classified based on the SLEEP-50 questionnaire: apnoea (n = 176), delayed sleep phase (n = 93), insomnia (n = 367), narcolepsei (n = 12) nightmares (n = 84), and PLMS/RLS (n = 184).

Results: The scores on the five processes were significantly elevated for all sleep disorders compared to people without sleep problems.There was a significant positive correlation between presence of sleep disorder and several of the insomnia cognitive processes even after accounting for levels of insomnia. Comorbidity was high in the sample.

Conclusion: This study expands upon Harvey's Cognitive Model of Insomnia by demonstrating its possible applicability beyond insomnia to a range of other sleep disorders. The results indicate that sleep-disturbing processes of insomnia might be applicable in other sleep disorders. The high comorbidity observed in this sample points to the complexity of sleep disorders. Future research should further investigate the mechanisms through which these processes contribute to different sleep disorders.

INTRODUCTION: Paradoxical intention (PI) is an insomnia treatment developed in the 1970s, which instructs patients to gently attempt to remain awake while in bed at night with the lights off. Previous research indicates PI's potential in improving insomnia, although no study has been conducted in the last few decades during which the insomnia diagnostic criteria have changed. Additionally, there are knowledge gaps regarding outcomes related to wake after sleep onset, the treatment mechanisms as well as the acceptability and feasibility of the treatment. This study therefore aims to address these gaps by assessing the potential mechanisms, preliminary efficacy, and patient experience and acceptability of PI.

METHODS AND ANALYSIS: We aim to include 40 adult participants with insomnia, aged 18 and above, from the Swedish general population. In this uncontrolled pilot study using a mixed-methods approach, both qualitative and quantitative data will be collected. The trial will be conducted on a self-help online platform, accessible from participants' homes, with weekly phone call support by therapists. Process and outcome measures will be assessed weekly across a 4-week intervention period and at a 3-month follow-up. A subset of participants will be asked to participate in qualitative semistructured interviews regarding the treatment.

ETHICS AND DISSEMINATION: Ethical approval for this project has been granted by the Swedish Ethical Review Authority (Dnr: 2023-06594-01). All participants will sign informed consent forms on a web service application prior to enrolment. From this mixed-methods study, we anticipate insights into the preliminary efficacy and mechanisms of paradoxical intention for treating insomnia, enriched by patient experience data. Results will be disseminated through peer-reviewed publications. The findings will inform adaptations to the treatment protocol and serve as groundwork for a possible larger scale randomised controlled trial.

TRIAL REGISTRATION NUMBER: NCT06259682.