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

INTERVENTION: This study evaluates a psychological treatment (verbal functional analysis) informed by Relational Frame Theory (RFT) on a comorbid sample within the areas of depression, anxiety and obsessive compulsive disorder (OCD) Participants meet therapists face‐to‐face individually at a health care center or a psychiatric outpatient clinic depending on the region of inclusion, for maximum 30 consecutive weeks, 1‐2 sessions a week, one hour at the time. The treatment is idiographical and principle based (operant learning according to an updated account of relational frame theory). The instruments for measuring the process aim to assess and influence participants maladaptive relating around themselves and others. Note that the following text include behavioral concepts from modern relational frame theory that may seem foreign or strange. Even though examples are routinely offered, a complete elaboration or translation is not be viable in this context. The following article may aid readers not accustomed to relational frame theory and the particular behavioral language accompanying it: Barnes‐Holmes, D., Barnes‐Holmes, Y., & McEnteggart, C. (2020). Updating RFT (more field than frame) and its implications for process‐based therapy. The Psychological Record, 1‐20. Key properties of patterns of verbal behavior are assessed through dialogue throughout the treatment. Clients often come into therapy asserting a specific problem (e.g., “I feel depressed”). These approached self‐labels may also possess avoidance functions of safety, justification, or comfort relative to a more distressing or aversive relational network (.e.g. I’m worthless or unlovable). As such, these seemingly aversive verbal stimuli (“I’m depressed”) have relatively appetitive func CONDITION: Major Depressive Disorder ;Panic Disorder;Agora Phobia;Social Anxiety Disorder;Obsessional Compulsive Disorder;Post‐Traumatic Stress Disorder ;Generalised Anxiety Disorder; ; Major Depressive Disorder ; Panic Disorder ; Agora Phobia ; Social Anxiety Disorder ; Obsessional Compulsive Disorder ; Post‐Traumatic Stress Disorder ; Generalised Anxiety Disorder Mental Health ‐ Anxiety Mental Health ‐ Depression Mental Health ‐ Other mental health disorders SECONDARY OUTCOME: Adherence ; ; Adherence are tracked by the therapist who takes notes on missed visits and rebooking session by session[continuously during treatment] ALIVE is used to assess psychological flexibility, 5 item scale, (Bond & Dowling personal Communication, 2019) [Pre, post (30 weeks post‐intervention commencement), and follow‐up at 2 and 6 months post‐intervention completion] Semi structured interview: ; ; Interview guide ; We are interested in your experience of the treatment ; ; 1) How have you experienced the treatment? ; ‐ how did you feel during the treatment? ; ‐ how did your mood change during the treatment? ; ; 2) Has anything changed for you during the treatment? ; ‐ has anything in your everyday life changed since you started the treatment? if yes: what / how? ; ‐ are you doing anything different since you started treatment? if so, what? ; ‐ how do you think people close to you would respond if we asked them if anything had changed with you since you started treatment? ; ‐ do you think differently in any way since you started treatment? ; o How do you think about yourself and others today compared to before you started treatment? ; o do you think noticeably more or less about something in particular today compared to before the treatment started? if so, what? ; o How do you think about responsibility and your ability to influence your situation today compared to before you started treatment? ; o How do you think about the future today compared to before you started treatment? ; ‐ did you learn anything new during the treatment? If yes: what? ; ‐ has something gotten worse or more difficult for you since the treatment started? if so, what? ; ‐ has anything gotten better or easier for you since the treatment started? if so, what? ; ‐ if something has changed: what, inside and outside the treatment, do you think may have influenced the change / changes? ; ; 3) What was helpful with the treatment? ; ; 4) What was difficult during the treatment? ; ‐ was anything painful during the treatment? ; ‐ was something difficult to understand about the treatment itself? ; ; 5). To what extent did you feel confident in a) the treatment and b) the therapist? ; ‐ how did the confidence in the treatment and the therapist vary during the course of the treatment? ; ; 7) Would you recommend anyone else to go for this treatment? ; If not, what are the main reasons? ; If so: what are the main reasons? ; o What recommendations would you give to someone else who has been offered to go for this type of treatment? ; 8) Is there anything you wish would have been different with the treatment? ; 9) Is there anything that you think is important for us to know about what it has been like for you to participate in the study / treatment, which we have not yet talked about?[Post treatment (30 weeks after treatment start)] The Brunnsviken Brief Quality of Life Scale (BBQ; Lindner et al., 2016) is used to assess for quality of life. [Pre, post (30 weeks post‐intervention commencement), and follow‐up at 2 and 6 months post‐intervention completion] The Credibility expectancy questionnaire (CEQ; Devilly & Borkovec, 2000) assess treatment credibility and expectancy, [Administered at session 5 only.] The Generalized Anxiety Disorder 7‐item scale (GAD‐7; Spitzer, Kroenke, Williams, & Löwe, 2006) is used to assess for symptoms of anxiety. [Pre, post (30 weeks post‐intervention commencement), and follow‐up at 2 and 6 months post‐intervention completion] The Liebowitz Social Anxiety Scale ‐ Self Report (LSAS‐SR; Baker, Heinrichs, Kim, & Hofmann, 2002) assesses symptoms among those with social anxiety disorder. [Pre, post (30 weeks post‐intervention commencement), and follow‐up at 2 and 6 months post‐intervention completion] The Negative Effects Questionnaire (NEQ; Rozental et al., 2019) is used to assess negative effects of psychological treatments, administered only at the end of treatment. ; [Pre, post (30 weeks post‐intervention commencement), and follow‐up at 2 and 6 months post‐intervention completion] The Patient Health Questionnaire‐9 (PHQ‐9; Kroenke, Spitzer, & Williams, 2001) is used to assess for symptoms of depression. [Pre, post (30 weeks post‐intervention commencement), and follow‐up at 2 and 6 months post‐intervention completion] The Posttraumatic Stress Disorder Checklist (PCL; Blevins, Weathers, Davis, Witte, & Domino, 2015) assesses symptoms for those with PTSD. [Pre, post (30 weeks post‐intervention commencement), and follow‐up at 2 and 6 months post‐intervention completion] The Yale‐Brown Obsessive Compulsive Scale (YBOCS; Goodman et al., 1989) assesses symptoms among those with OCD. [Pre, post (30 weeks post‐intervention commencement), and follow‐up at 2 and 6 months post‐intervention completion] INCLUSION CRITERIA: (1) participant is at least 18 years of age and (2) have a minimum of two comorbid psychiatric disorders within anxiety disorders, obsessive‐compulsive disorder and depression. (3) if regular pharmacological treatment for anxiety, obsessive‐compulsive disorder, depression and eating disorder occurs, participation require stable doses for at least two months before the start of the measurements is allowed. (4) participants must have undergone conventional treatment for one of their current diagnoses previously. (5) fluent in Swedish (6) have access to internet and able to use smartphone or computer (7) able to attend sessions on regular weekdays (9‐5pm) 1‐2 times a week PRIMARY OUTCOME: Daily idiographic assessment (DIA) ; The daily idiographic assessments (DIA) consists of four questions that assess the participants relating, orienting evoking functions and verbal tracking inferred from relational fram theory. The scale was designed specifically for this study. ; ; CONSIDER THE LAST DAY; ; Orienting; ; How often do the things that you are trying to work through come to mind?; 0 = Not at all often ‐ 10 = All the time; ; ; Relating; ; Describe below the issues, struggles or difficulties that you have spent most time trying to resolve?; textbox; ; ; Evoking; ; How willing would you be to tell numerous people you know about the things that you are trying to figure out?; 0 = Not at all willing ‐ 10 = completely willing ; ; ; Verbal tracking; ; In addition to your struggle, do you believe that you have enough headspace and energy to comfortably manage other aspects of your life?; 0 = No space at all ‐ 10. Plenty of space; ; ; [Daily measures during baseline phase (7‐21 days prior to treatment), during treatment phase (30 weeks) and one week post treatment as well as one week during follow‐up measurements at 2 and 6 months. I.e., the daily measures will not occur between one week after the treatment has ended and until the first follow‐up measurements are conducted. Also, they will not occur between the first and the second follow‐up measurement phase.] Weekly idiographic assessment (WIA) ; The weekly idiographic assessment consists of 6 questions that assess shifts in the dimensions of relating and choice inferred from relational frame theory.; The scale was designed specifically for this study. ; ; CONSIDER THE LAST WEEK; ; Flexibility; ; Do you always think the same way about what you are trying to sort out?; 0 = No, it differs from context to context ‐ 10 = Yes, in all contexts; ; ; Complexity; ; If you were given the task of describing what you are trying to sort out in an understandable way, how much space would you need then?; 0 = A few words would suffice ‐ 10 = Very many words would be required; ; ; Derivation; ; Has anything new come up, that makes you look at what you are trying to sort out in a different way?; 0 = no, not at all ‐ 10 = very much new has been added; ; ; Coherence; ; Have you figured out (or found) that something you previously thought about X might not be true?; 0 = No, not at all ‐ 10 = Yes, all; ; ; Valued action (Choice); ; Have you noticed any experiences, behaviours or even just thoughts and feelings that you had this week that seemed different to you?; 0 = Not at all ‐ 10 = Yes, everything is different now; ; Describe (concisely) what has been different:; textbox; [Weekly measures during baseline phase (7‐21 days prior to treatment), during treatment phase (30 weeks) and once post treatment as well as once during follow‐up measurements at 2 and 6 months. I.e., the weekly measures will not occur between one week after the treatment has ended and until the first follow‐up measurements are conducted. Also, they will not occur between the first and the second follow‐up measurement.]