How CBT Helps Rebuild Self-Esteem in Methamphetamine Recovery

Adam, A., Hanafi, A., Nurfaizah, S., & Alim, A. (2023). Experimentation test of cognitive behavioral therapy techniques on recovery motivation for drug addicts. East African Scholars Journal of Psychology and Behavioural Sciences, 5(4), 77–88. https://doi.org/10.36349/easjpbs.2023.v05i04.002

Summary by: Naya Twal

Self-esteem can be one of the psychological resources affected by addiction and an important part of the recovery process. For individuals struggling with methamphetamine use, feelings of shame, guilt, and diminished self-worth may create additional challenges during rehabilitation. A study conducted at LRKM Mitra Husada in South Sulawesi, Indonesia, offers promising insights into how Cognitive Behavioral Therapy (CBT) may help improve self-esteem among people undergoing treatment for methamphetamine use.

Methamphetamine use remains a serious public health concern, both in Indonesia and worldwide. Beyond its physical and behavioral consequences, problematic substance use can also affect emotional well-being, confidence, and perceptions of personal worth. Against this backdrop, interventions that target not only substance-related behaviors but also cognitive and emotional functioning are particularly valuable.

Adam et al. (2023) explored whether a structured, five-session CBT counseling program could improve self-esteem among methamphetamine users enrolled in outpatient rehabilitation. The study involved 36 participants in a quasi-experimental design, divided into two groups of 18. One group received CBT, while the control group received educational brochures. Self-esteem was assessed before and after the intervention using the Rosenberg Self-Esteem Scale (RSES), with participants classified into low, moderate, and high self-esteem categories.

The results were promising. Participants who received CBT showed a statistically significant improvement in self-esteem (p < .001). The average coded self-esteem category increased from 1.61 to 2.67 on a three-level scale. Even more encouraging was the shift in self-esteem categories: the proportion of individuals with low self-esteem dropped from 44.4% to zero, while those classified as having high self-esteem increased from 5.6% to 66.7%. Meanwhile, the control group showed no statistically significant change (p = .257). The researchers also reported a significant difference between the groups at post-test (p = .003).

Why might CBT make such a difference? CBT helps individuals identify and challenge negative thought patterns that may reinforce shame, hopelessness, and self-blame. For people who enter treatment struggling with guilt or a sense of personal failure, learning to develop more balanced and constructive self-beliefs may support psychological recovery. The intervention used in this study included identifying cognitive distortions, recognizing triggers and cravings, planning daily activities, practicing positive self-talk, and developing relapse-prevention and substance-refusal skills. Together, these techniques aimed to strengthen both self-esteem and practical coping abilities.

Of course, the study is not without limitations. Its small sample size, quasi-experimental design, and reliance on a single rehabilitation center mean that the findings should be interpreted cautiously. The assessment was limited to short-term changes in self-esteem, and the study did not establish whether these improvements were sustained over time. Additionally, substance use outcomes and relapse rates were not directly measured, making it difficult to determine whether increased self-esteem translated into long-term recovery success.

Nevertheless, the findings point to a promising direction: integrating CBT into addiction rehabilitation programs may help strengthen psychological resources that are important for recovery. Further controlled studies with larger samples and longer follow-up periods are needed to determine whether these benefits persist and contribute to broader treatment outcomes.

Ultimately, strengthening self-esteem is more than a superficial goal. Feeling capable of change and developing a more positive sense of self may support motivation, resilience, and the ability to cope with setbacks. Although this study cannot establish lasting recovery benefits, it suggests that CBT may help individuals begin rebuilding their sense of self-worth as part of the rehabilitation process.

Effect of computer-assisted cognitive behavior therapy vs usual care on depression among adults in primary care: A randomized clinical trial

Wright, J. H., Owen, J., Eells, T. D., Antle, B., Bishop, L. B., Girdler, R., Harris, L. M., Wright, R. B., Wells, M. J., Gopalraj, R., Pendleton, M. E., & Ali, S. (2022). Effect of computer-assisted cognitive behavior therapy vs usual care on depression among adults in primary care: A randomized clinical trial. JAMA Network Open, 5(2), Article e2146716. https://doi.org/10.1001/jamanetworkopen.2021.46716 

Summary by: Ethan Leon Rosenthal

Introduction

The study by Wright et al. (2022), published in JAMA Network Open, investigates the effectiveness of computer-assisted cognitive behavioral therapy (CCBT) combined with treatment as usual (TAU) compared to TAU alone in treating depression among primary care patients. The rationale behind this research stems from the growing demand for scalable, evidence-based psychological treatments for depression. Traditional CBT is well established as an effective intervention, yet its accessibility remains limited due to shortages of trained therapists and high treatment costs. The authors hypothesized that computer-assisted CBT with limited clinician support could maintain effectiveness while reducing the burden on healthcare systems.

The objectives of the study were:

1. To evaluate the effectiveness of CCBT compared with treatment as usual (TAU) in primary care patients with depression.

2. To evaluate the feasibility of CCBT in a primary care population with substantial numbers of patients with low levels of education, reading skills, and/or internet access.

3. To perform an exploratory analysis of factors associated with differences in treatment outcomes.

4. To evaluate the medical care utilization costs of CCBT compared with TAU.

The authors noted that the economic analysis would be reported separately.

Study Design

This randomized clinical trial (RCT) was conducted in primary care practices in Kentucky, United States. A total of 175 adult participants who scored at least 10 on the Patient Health Questionnaire-9 (PHQ-9) were enrolled and randomly assigned to two groups: CCBT + TAU (n = 95) and TAU alone (n = 80). Most participants had a primary diagnosis of major depressive disorder (MDD), although not all met the diagnostic criteria. The mean age was approximately 47 years.

The study also included substantial numbers of patients with lower incomes, limited educational attainment, and lower reading proficiency, addressing populations often underrepresented in earlier research on digital psychological interventions.

Procedure

Participants in both groups received routine care from their primary care physicians, which could include medication, referrals, or other supportive measures.

The intervention group also received access to a computer-based CBT program called Good Days Ahead (GDA), which included nine interactive lessons focused on CBT principles and techniques. Participants were encouraged to complete the program over 12 weeks and could receive up to 12 weekly telephone support sessions from a master's-level mental health clinician. These sessions were designed to provide guidance, monitor progress, and encourage engagement, with approximately 20 minutes of support planned per week.

To improve accessibility, the researchers also provided laptops with internet access to participants who needed them.

The primary outcome was depression severity, measured by the Patient Health Questionnaire-9 (PHQ-9) at baseline, after 12 weeks of treatment, and at 3- and 6-month follow-ups following treatment completion. Secondary outcomes were measured using the Automatic Thoughts Questionnaire (ATQ) for negative cognitions, the Generalized Anxiety Disorder-7 (GAD-7) for anxiety symptoms, and the Satisfaction with Life Scale (SWLS) for life satisfaction. Treatment satisfaction was also assessed using the Client Satisfaction Questionnaire-8 (CSQ-8).

Results

The findings demonstrated statistically significant improvements in the CCBT + TAU group compared with TAU alone. PHQ-9 scores decreased over time in both treatment groups. However, greater improvements were observed in the CCBT group after treatment (mean difference = −2.5; 95% CI, −4.5 to −0.9; p = .005; Cohen's d = −0.42). These differences were maintained at the 3-month (mean difference = −2.3) and 6-month (mean difference = −3.2) follow-ups.

There were also statistically significant differences favoring CCBT over TAU on the GAD-7, ATQ, and SWLS measures at all assessment points, except for the GAD-7 at the 6-month follow-up.

Importantly, the effect size of CCBT over TAU was moderate (Cohen's d = −0.42) at posttreatment. Response and remission rates were also significantly higher in the CCBT group. At the end of treatment, 58.4% of the CCBT group showed a treatment response compared with 33.1% of the TAU group. Remission rates were 27.3% and 12.0%, respectively.

The results also indicated that completing more GDA modules was associated with greater improvement in depressive symptoms. Furthermore, patients receiving CCBT reported higher treatment satisfaction than those receiving TAU.

Discussion

These results provide evidence that computer-assisted CBT with clinician support can be an effective and potentially scalable option for treating depression in primary care. The findings support the hypothesis that guided digital interventions can improve treatment outcomes while reducing the amount of direct clinician time required.

The researchers reported that participants received an average of less than three hours of clinician support over the entire treatment period. This suggests that CCBT may offer an efficient method of delivering evidence-based psychological care. However, the study did not directly establish its cost-effectiveness.

Wright et al. highlight that one of the major barriers to effective mental health care is limited access to evidence-based psychotherapy. By implementing CCBT within primary care, healthcare systems may be able to provide more accessible treatment to patients who would otherwise face barriers to psychological care.

An important strength of the study was its inclusion of participants with lower incomes, limited education, and restricted internet access. This broadens the relevance of the findings to populations that have often been excluded from previous studies of digital mental health interventions.

However, the study also has several limitations. First, the sample was predominantly female, and participants were recruited from a limited number of primary care practices in Kentucky, which may restrict generalizability to other populations and healthcare settings. Moreover, the follow-up period of six months after treatment completion may not fully capture longer-term outcomes.

Another important limitation is the lack of an active comparison group receiving traditional face-to-face CBT or an equivalent amount of clinician support without the computer program. Therefore, the study cannot establish whether CCBT is equally effective as conventional CBT or determine how much of the observed improvement was attributable specifically to the digital component.

Additionally, treatment as usual was not standardized, and missing follow-up data may have influenced the results. Although CCBT significantly reduced depressive symptoms, a substantial proportion of participants did not achieve remission, indicating that further treatment or additional support may still be necessary.

Conclusion

Overall, the findings suggest that clinician-supported CCBT can be a valuable addition to depression treatment in primary care. The intervention produced greater reductions in depressive symptoms and higher remission rates than treatment as usual alone, while requiring relatively limited clinician contact.

Although further research is needed to clarify its cost-effectiveness and long-term outcomes, the study highlights the potential of digital psychological interventions to improve access to evidence-based care, particularly for patients who face financial, educational, or technological barriers to treatment.

Providing Antiracist Cognitive Behavioral Therapy: Guidelines, tools, and tips

Cenat, J. M., Haeny, A. M., & Williams, M. T. (2024). Providing antiracist cognitive-behavioral therapy: Guidelines, tools, and tips. Psychiatry Research, 339, 116054. https://doi.org/10.1016/j.psychres.2024.116054

Summary by: Lama Moussa

The article by Cénat et al. (2024) contends that existing adaptations of cognitive behavioral therapy (CBT) have often insufficiently addressed the mental health needs of racialized individuals because they do not adequately incorporate systemic, institutional, interpersonal, and internalized racism or the effects of complex racial trauma. These omissions may contribute to less effective therapeutic outcomes and the persistence of existing disparities. In response, the authors introduce a comprehensive framework for antiracist CBT designed to improve mental health care, build trust within racialized communities, and contribute to the decolonization of therapeutic practices.

Implementing antiracist CBT requires changes in clinical practice, beginning with thorough clinician self-development. This process includes self-reflection to identify and address personal racial biases, as well as the development of antiracist competencies. These competencies encompass an understanding of microaggressions and multiple forms of racism, the capacity to engage in open discussions about race, accurate assessment of racial stress and trauma, cultural competence, non-defensive responses to feedback, and the ability to teach effective coping strategies.

In addition to individual clinician development, the article calls for a reconsideration of the CBT theoretical framework. The conventional CBT triangle—thoughts, feelings, and behaviors—is expanded to explicitly include the environment and social context as important influences on psychological functioning. This revised model incorporates multiple levels of racism, including interpersonal, institutional, structural, and systemic forms, as well as disparities in access to resources, race-based stress, and complex racial trauma. Such reframing moves CBT toward a more comprehensive approach that better reflects the realities faced by racialized individuals.

The article outlines practical strategies for implementing antiracist CBT, highlighting the importance of a proactive and empathetic clinical stance. Clinicians are encouraged to acknowledge the impact of racism, validate patients' experiences, and establish trust. Addressing complex racial trauma, which may arise from repeated and cumulative experiences of racism, involves challenging internalized racism through cognitive restructuring and fostering positive cultural and racial identity. When clinically appropriate, patients may be supported in processing racial trauma through different therapeutic approaches, including imaginal exposure and meaning-making from a posttraumatic growth perspective. Additionally, clinicians can assist patients by helping them challenge self-blaming interpretations, externalize responsibility for discriminatory experiences, develop racial pride, strengthen coping mechanisms, and increase their capacity for self-advocacy.

Another important aspect of antiracist CBT is addressing the specific needs of children, adolescents, and families, recognizing that competencies developed for adult CBT are not directly transferable to these populations. The use of the informant version of the Cultural Formulation Interview (CFI) may help clinicians better understand families' cultural and racial contexts and address historical mistrust. Clinicians are encouraged to foster culturally and racially safe therapeutic environments by demonstrating respect for cultural norms, advocating for systemic reforms, and obtaining specialized training to work effectively with young people and families. Strengthening parent-child relationships and supporting positive ethnic and racial identity development may also contribute to resilience and psychological well-being.

Although the proposed framework offers valuable guidance for clinical practice, it is important to recognize that the article presents recommendations rather than findings from a controlled intervention study. Therefore, the effectiveness of the proposed adaptations has not been directly established by this publication. Further empirical research is needed to evaluate whether antiracist CBT improves treatment outcomes, strengthens therapeutic relationships, and reduces disparities in access to and engagement with mental health services.

In summary, the article presents an important framework for adapting CBT into an antiracist therapeutic approach. By establishing guidelines for clinician self-development, promoting a revised theoretical model that incorporates environmental and systemic racism, and offering practical interventions for racial trauma, the authors address significant gaps in mental health care. The adoption of these strategies may improve the responsiveness and effectiveness of CBT, increase trust in mental health services, and contribute to more equitable and culturally sensitive care. Overall, the article provides a useful foundation for further research and clinical development aimed at addressing racism within psychological treatment.

Improvement in adult anxious and avoidant attachment during cognitive behavioral therapy for panic disorder

Zalaznik, D., Weiss, M., & Huppert, J. D. (2019). Improvement in adult anxious and avoidant attachment during cognitive behavioral therapy for panic disorder. Psychotherapy Research, 29(3), 337-353.

Summary by: Sofija Miljovic

One of the psychological treatments for panic disorder that has been shown to be effective and is well established in the literature is cognitive behavioral therapy (CBT). It is generally described as a time-limited, structured therapy that addresses dysfunctional thought patterns and avoidance behaviors. Attachment theory, however, has traditionally emphasized the relative stability of internal working models of relationships developed in early life. Zalaznik, Weiss, and Huppert’s (2019) study is a valuable addition to the clinical literature, as it asks whether CBT, although not specifically designed to address attachment, might positively influence adult attachment patterns. Using this study as an illustrative example, this article critically discusses the theoretical background, methodology, findings, and implications of the research and offers a personal reflection on its scientific and clinical relevance.

The primary objective of the study was to determine whether attachment anxiety and avoidance decrease during CBT for panic disorder with agoraphobia. The researchers used a longitudinal design involving 31 adults diagnosed with panic disorder and agoraphobia. Participants received structured CBT, an approach that typically involves psychoeducation about the physiology of panic, cognitive restructuring of catastrophic interpretations of bodily sensations, interoceptive exposure to feared bodily sensations, and gradual in-vivo exposure to feared situations. Before each session, participants completed self-report questionnaires assessing attachment anxiety and avoidance, anxiety sensitivity, agoraphobic avoidance behaviors, emotion regulation, and the therapeutic alliance. The repeated measurements allowed the authors to examine changes throughout treatment and investigate the temporal relationships between different psychological processes.

For the statistical analysis, the researchers employed multilevel modeling to account for repeated measurements nested within individuals. Moreover, they performed time-lagged analyses to examine whether changes in attachment preceded or followed changes in panic-related symptoms and psychological processes. The findings showed improvements in both anxious and avoidant attachment during therapy. Changes in anxiety sensitivity were associated with changes in both attachment dimensions. Improvements in avoidance behaviors when participants were alone, but not when accompanied by another person, were also associated with changes in attachment. Importantly, reductions in anxiety sensitivity and avoidance when alone predicted reductions in attachment anxiety in the following session, but not vice versa. Similarly, reductions in avoidance behaviors and emotional suppression preceded improvements in attachment avoidance. The therapeutic alliance also improved, although its changes were associated only with simultaneous changes in attachment anxiety. Overall, these temporal patterns suggest that improvements in attachment may follow changes in panic-related psychological processes rather than act as an initial mechanism of symptom reduction.

These results have several theoretical implications. First, they suggest that adult attachment patterns might be more flexible than traditionally assumed, at least in clinical populations receiving structured psychological treatment. Second, they challenge the distinction commonly drawn between symptom reduction and deeper changes in personality or relational functioning. Rather, the findings support a more integrative perspective in which cognitive, emotional, and interpersonal processes may influence one another. CBT methods, including exposure and cognitive restructuring, might help improve a person's sense of mastery, emotional safety, and confidence in their coping skills. These improvements could potentially extend to interpersonal situations and contribute to reduced attachment insecurity. However, this possible mechanism remains a theoretical interpretation rather than a directly established finding.

Despite its contribution, the study has notable limitations. The sample size was relatively small, which limits statistical power and the ability to generalize the findings to broader populations. Also, the lack of a control group makes it challenging to determine whether changes in attachment resulted specifically from CBT rather than the passage of time, expectancy effects, or the general therapeutic relationship. The reliance on self-report measures of attachment also raises concerns about possible response biases, including socially desirable responding. Furthermore, although the time-lagged analyses provide information about the sequence of changes, they cannot establish causal relationships. Without long-term follow-up data, it is also unclear whether these improvements represent lasting changes in attachment patterns. These shortcomings suggest that the findings should be considered promising but preliminary.

As a student, I find this work especially compelling because it brings together two traditions in psychology that are often introduced as distinct approaches. I appreciate that the authors did not present their findings as definitive evidence of causation, but instead highlighted associations between changes in attachment and other psychological processes. The most useful contribution of this study, in my opinion, is not that it proves CBT alters attachment, but that it introduces an important line of inquiry into the broader effects of evidence-based psychological interventions. At the same time, I remain skeptical about the strength of the evidence. These changes cannot yet be established as genuine, lasting changes in attachment patterns without experimental control and long-term follow-up data demonstrating that the improvements extend beyond temporary changes in self-reported relational functioning.

To sum up, the article by Zalaznik, Weiss, and Huppert (2019) provides valuable empirical evidence that CBT for panic disorder with agoraphobia is associated with reductions in attachment anxiety and avoidance. The study offers an important starting point for future research, although its methodological limitations restrict the strength of the conclusions. Larger controlled studies with long-term follow-up are needed to determine whether these attachment changes are stable and clinically significant over time. Overall, this study contributes to a more nuanced understanding of how psychological interventions may influence not only symptoms but also underlying relational patterns.

Effectiveness of Cognitive Behavioral Therapies of Varying Complexity in Reducing Depression in Adults

Angelakis, I., Huggett, C., Gooding, P., Panagioti, M., & Hodkinson, A. (2022). Effectiveness of cognitive–behavioural therapies of varying complexity in reducing depression in adults: systematic review and network meta-analysis. The British Journal of Psychiatry, 221(2), 459–467. 

Summary by: Jessica Freij

A major global health problem, depression, affects hundreds of millions of people worldwide. Although cognitive behavioral therapy (CBT) is widely used in treating depression, its structure and delivery vary widely. To examine how different levels of CBT complexity compare in reducing depressive symptoms in adults, Angelakis et al. (2022) conducted a systematic review and network meta-analysis. Specifically, they examined whether increasing CBT complexity produces stronger treatment effects and whether individual and contextual factors affect treatment outcomes.

Three levels of complexity were established by the authors for cognitive behavioral therapy. Core CBT is based on behavioral activation and/or cognitive restructuring. Complex CBT includes one additional therapeutic component alongside these core techniques. Ultra-complex CBT incorporates the core components along with two or more additional strategies, such as relapse prevention and problem solving. Using standardized mean differences (SMDs), the authors compared outcomes across trials using different depression scales, including the Beck Depression Inventory (BDI), among others.

The review included 107 randomized controlled trials with 15,248 participants, ranging in age from young adulthood to older adulthood, with an average age of approximately 41. Both clinically diagnosed patients and those identified through validated self-report measures such as the BDI were included in the study. Among the studies reporting comorbidities, anxiety disorders and chronic physical illnesses were common. CBT was delivered individually, in groups, and in online formats, and treatment duration and session frequency varied widely. The variability in treatment duration and frequency increased real-world applicability but also led to considerable heterogeneity. To compare multiple treatments simultaneously, the authors used a network meta-analysis and evaluated study quality using the RoB 2 tool and CINeMA framework. Credible intervals (CrIs) were used to express uncertainty around the estimated treatment effects.

After treatment, all three types of CBT showed better outcomes compared to no treatment. Although ultra-complex CBT ranked highest in terms of effectiveness, followed by complex CBT and then core CBT, the differences between the CBT approaches were not clearly established at post-treatment. The authors also expressed the estimated effects in BDI points to make the reductions in depressive symptoms easier to interpret. SUCRA rankings placed ultra-complex CBT as the most likely to be the most effective option. At follow-up of 26 weeks or more, ultra-complex and complex CBT maintained statistically significant benefits compared with no treatment, whereas core CBT did not show a statistically significant long-term advantage. These results suggest that additional therapeutic components might help sustain progress after treatment ends.

Treatment effectiveness was influenced by both individual and contextual factors, as revealed by moderator analyses. Individuals with comorbid mental health problems appeared to benefit more from ultra-complex CBT, suggesting that additional structured interventions may be particularly useful in complex clinical presentations. The age of individuals influenced outcomes as well: younger adults responded best to ultra-complex CBT, whereas adults aged 31–59 benefited more from complex CBT. Both complex and ultra-complex CBT showed greater improvement in individuals from lower socioeconomic backgrounds, and ultra-complex CBT was effective even when delivered by non-mental health specialists. In contrast, core CBT delivered in a group format appeared relatively less effective, although this finding was based on a small number of studies and should be interpreted with caution.

The large number of randomized trials and participants included in the review provides a substantial evidence base. Additionally, it is the first review to categorize CBT specifically by complexity, providing new insight into how structural differences influence outcomes. Because many meta-analyses focus only on the immediate effects of treatment, long-term outcomes add considerable value. Furthermore, the use of rigorous methods such as RoB 2 and CINeMA strengthens the methodological approach, although the certainty of the findings varied across comparisons.

A few limitations exist, however. Considerable heterogeneity across studies, due to differences in participant characteristics, intervention formats, and treatment timelines, makes the findings more difficult to interpret. There was also evidence of publication bias, suggesting that studies with weaker or null results may have been underrepresented. It is difficult to determine how concurrent medication may have impacted outcomes because reporting of antidepressant use was inconsistent. Additionally, the wide differences in session length and treatment duration made it harder to directly compare the different CBT categories. Studies involving patients with comorbid personality disorders were also absent from the analysis.

Although there are some limitations, this study still provides useful takeaways for clinical practice. The findings challenge the idea that all CBT formats are equally effective in the long term and suggest that treatment complexity may matter. Ultra-complex CBT showed particularly promising long-term results, especially for those with comorbid mental health conditions. Complex CBT also demonstrated sustained benefits and may work well for many adult patients, while core CBT remains a valuable option, particularly for those without comorbid conditions. Overall, the results emphasize the importance of tailoring treatment structure to factors like age, comorbidity, socioeconomic background, and care setting, while also considering accessibility, staff availability, and costs.

The authors highlighted several key priorities for future research. They stressed the importance of clearer reporting on antidepressant use to better understand how medication works in combination with psychological therapy. More studies should include people with comorbid personality disorders, who were not represented in the included trials. Researchers should also specify exactly which CBT components are part of their interventions and examine patient factors that might affect treatment outcomes. Finally, further long-term follow-up studies would help clarify how well the benefits hold up over time.

Efficacy of Short-Term CBT for Internet and Computer Game Addiction

 Wölfling, K., Müller, K. W., Dreier, M., Ruckes, C., Deuster, O., Batra, A., Mann, K., Musalek, M., Schuster, A., Lemenager, T., Hanke, S., & Beutel, M. E. (2019). Efficacy of short-term treatment of internet and computer game addiction. JAMA Psychiatry, 76 (10), 1018. https://doi.org/10.1001/jamapsychiatry.2019.1676 

Summary by: Vali Ibrahimi

Introduction

The article by Wölfling et al. (2019) starts off by discussing internet and computer game addiction in relation to the diagnostic frameworks of the DSM-5 and ICD-11. While internet gaming disorder was included in the DSM-5 as a condition for further study, gaming disorder was recognized as a disorder in the ICD-11. Wölfling et al. (2019) discuss the broader concept of Internet Addiction (IA), which includes several different subtypes. The authors note a higher prevalence of gaming-related IA in men, as well as an estimated prevalence rate of 3% to 6% for IA, alongside associated psychosocial impairment and comorbidity.

CBT has been suggested as a suitable treatment option for targeting dysfunctional cognitions, coping strategies, motivation, and the development of alternative activities, but previous research has shown considerable methodological limitations. To address this gap, Wölfling et al. (2019) developed the Short-term Treatment of Internet and Computer game Addiction (STICA), a manualized CBT program that combines individual and group therapy and had shown promising effects in a pilot study. Wölfling et al. (2019) designed a multicenter, randomized, observer-blind clinical trial to test the efficacy of STICA on remission and related outcomes in men with IA.

Methodology

The multicenter randomized controlled trial (RCT) was conducted in four outpatient clinics in Germany and Austria. Men aged 17–55 who had met the criteria for IA within the past six months, based on clinician-rated AICA-C and self-report AICA-S assessments, were eligible to participate. Participants were randomly assigned in a 1:1 ratio using computer-generated lists to either the STICA or wait-list control (WLC) group. Independent clinicians assessing the outcomes were blinded to treatment allocation.

STICA consisted of 15 weekly group sessions lasting 100 minutes, along with up to eight individual sessions of 60 minutes over approximately four months. The sessions were conducted by CBT therapists who had received training and regular supervision to ensure treatment fidelity. Assessments occurred at baseline (T0), mid-treatment (2 months, T1), post-treatment (4 months, T2), and a 6-month follow-up for the STICA group only (T3).

The primary endpoint was remission of IA at T2, defined as an AICA-S score of less than 7. Secondary endpoints included IA symptom severity, time spent online, psychosocial functioning, and depressive symptoms. The sample-size planning targeted 192 participants, based on pilot remission rates and an assumed 20% remission rate for the WLC group, but recruitment ultimately yielded an analyzed sample of 143 participants.

Results

Of the 149 initially randomized men, six withdrew from participation, leaving 143 participants in the analyzed sample, with 72 in the STICA group and 71 in the WLC group.

At post-treatment, remission (as measured by AICA-S) was higher in the STICA group (69.4%) compared to the WLC group (23.9%), with an adjusted odds ratio (OR) of 10.10 (95% CI, 3.69–27.65). Secondary outcome analyses also favored the STICA group, with larger reductions in self-reported IA symptoms (d = 1.19) and weekday time spent online (d = 0.88), as well as improved psychosocial functioning (GAF, d = 0.64).

Depressive symptoms improved in both groups, but the time × treatment interaction was not statistically significant. At the 6-month follow-up, 80.6% of the 36 contacted STICA participants scored below the cutoff for IA. However, only half of the original STICA group participated in this follow-up assessment. Clinician-rated outcomes measured by AICA-C also favored the STICA group, with a large effect size (d = 0.80).

Completion rates were 65.3% for STICA and 74.6% for the WLC group, with lack of adherence and missed sessions among the most common reasons for dropout.

Discussion

Wölfling et al. (2019) conclude that this is the first multicenter, observer-blind RCT to demonstrate that a manualized CBT program can achieve markedly higher remission rates and improvements in psychosocial functioning among men with IA compared to a wait-list control. The improvements reported by participants were also supported by clinician-rated assessments.

The authors also note small improvements in the WLC group, which may have been related to repeated assessment contacts and expectations of future treatment. These findings highlight the need for controlled study designs and suggest that previous pre-post studies may have overestimated treatment effects.

The study's limitations include a smaller sample size than the originally planned 192 participants, reliance on self-report measures for the primary endpoint rather than clinician-rated assessments, and male-only eligibility, which limits the generalizability of the findings to women. Furthermore, exclusion criteria based on certain comorbid mental disorders reduce the representativeness of the sample. The absence of a WLC group at the 6-month follow-up, along with the high loss to follow-up in the STICA group, also limits conclusions about the long-term effectiveness of the treatment.

Finally, Wölfling et al. (2019) recommend that future studies prioritize participant retention, include active treatment comparators, examine the potential benefits of combining CBT with pharmacological treatment, and test the effectiveness of STICA in women as well.

The Effectiveness of Schema Therapy in Individuals Who Committed Crimes

Sousa, M., Gouveia, C., Cunha, O., & de Castro Rodrigues, A. (2024). The Effectiveness of Schema Therapy in Individuals Who Committed Crimes: A Systematic Review. Trauma, Violence & Abuse, 25(5), 3631–3642. https://doi.org/10.1177/15248380241254082 

Summary by: Joelle Shadi Fawaz Haddadin

Studies have shown that schema therapy is a promising therapeutic approach in several areas of psychology, including forensic psychology. In this paper, I will be reviewing a comprehensive systematic review conducted in 2024 by Sousa and colleagues, which assessed whether schema therapy is effective in reducing psychological symptoms as well as risk factors associated with criminal behavior among offenders. Out of an initial pool of 886 papers, the review identified 15 studies that met the inclusion criteria and analyzed their findings. The studies were found across multiple databases and were conducted in a variety of countries, with predominantly male participant pool.

Now, one may ask what sets schema therapy apart from the traditional Cognitive Behavioral Therapy (CBT) we are used to using in such cases. Well, schema therapy focuses on deeper underlying issues by exploring the emotional and developmental patterns that individuals develop, known as early maladaptive schemas (EMSs). In turn, this approach can help address the effects of traumatic experiences, impulsivity, and deeply ingrained personality patterns that may contribute to offending behavior.

The findings of the reviewed studies showed generally positive results. Offenders who received schema therapy often demonstrated reductions in early maladaptive schemas and maladaptive schema modes, as well as decreases in factors associated with criminal behavior, such as anger, paranoia, and cognitive distortions. Some studies also reported improvements in symptoms linked to personality disorders, including antisocial personality disorder and psychopathic traits, which is consistent with the theoretical literature on schema therapy.

Moreover, schema therapy didn't only reduce negative traits within these individuals but also helped develop some positive ones. For instance, studies observed improvements in emotional regulation, self-esteem, and interpersonal functioning. Additionally, one prominent example of the noticeable difference after intervention was seen in research conducted by Bernstein and colleagues, where offenders receiving schema therapy advanced more rapidly through forensic rehabilitation milestones compared to those receiving treatment as usual (TAU). Case studies included in the review also showed reductions in certain violence risk factors and improvements in interpersonal functioning, even within high-risk offender populations.

Schema therapy was also found to be promising in the form of schema therapy-based programs. The CONTIGO program, intended for intimate partner violence offenders, had a recidivism rate of 15.4% among participants who completed the program. However, this finding alone does not prove that the program prevented reoffending. Similarly, Portugal's Growing Pro-Social (GPS) program reduced anger, cognitive distortions, and early maladaptive schemas, with improvements maintained at a 12-month follow-up.

Nonetheless, the results weren't unanimous across all studies, and the review had some limitations that should be taken into consideration. The studies didn't all have the same research quality. Some used methodologically stronger randomized controlled trials, while others consisted of smaller samples and less consistent treatment protocols. One study found no significant improvements in most of the outcomes measured after treatment. Furthermore, several studies examined the same intervention program, and almost all participants were male, which limits how broadly the findings can be generalized. Hence, it would be beneficial for the field as a whole to conduct more high-quality trials and track long-term outcomes like recidivism.

Overall, this systematic review provides promising evidence for the effectiveness of schema therapy among offenders. By addressing deeply rooted maladaptive schemas and emotional and developmental patterns, this approach may help reduce personality disorder symptoms and risk factors associated with criminal behavior while improving emotion regulation. However, its effectiveness in preventing recidivism still needs further investigation.

This study offers only a glimpse into the potential effects of schema therapy on offenders, and more robust, larger-scale research is needed to confirm the results found in these studies. These findings suggest that schema therapy could not only help offenders manage their behavior but also support longer-term psychological change and potentially contribute to improvements in correctional rehabilitation programs.