Psychology Commons^™

Behavioral Inhibition And Activation As A Modifier Process In Autism Spectrum Disorder: Examination Of Self‐Reported Bis/Bas And Alpha Eeg Asymmetry, Hillary K. Schiltz, Alana J. Mcvey, Alexander Barrington, Angela D. Haendel, Bridget Dolan, Kirsten S. Willar, Sheryl Pleiss, Jeffrey S. Karst, Elisabeth M. Vogt, Christina C. Murphy, Kelsey Gonring, Amy V. Van Hecke

Psychology Faculty Research and Publications

The Modifier Model of autism spectrum disorder (ASD) suggests that phenotypic variability within ASD is rooted in modifier processes, such as the behavioral inhibition system (BIS) and behavioral activation system (BAS). Among a sample of 53 adolescents with ASD, this study examined associations between (a) self-reported BIS/BAS and frontal and parietal alpha electroencephalogram asymmetry and whether these indices related to (b) ASD severity (via the Autism Quotient), and/or (c) co-occurring anxiety and attention-deficit hyperactivity disorder (via Youth Self Report and Child Behavior Checklist). Findings showed that alpha asymmetry was associated with self-reported BAS scores, such that greater BAS was related …

Differentiating Tic-Related From Non-Tic-Related Impairment In Children With Persistent Tic Disorders, Jordan T. Stiede, Jennifer R, Alexander, Brianna Wellen, Christopher C. Bauer, Michael B. Himle, Suzanne Mouton-Odum, Douglas W. Woods

Psychology Faculty Research and Publications

Children with persistent (chronic) tic disorders (PTDs) experience impairment across multiple domains of functioning, but given high rates of other non-tic-related conditions, it is often difficult to differentiate the extent to which such impairment is related to tics or to other problems. The current study used the Child Tourette's Syndrome Impairment Scale - Parent Report (CTIM-P) to examine parents' attributions of their child's impairment in home, school, and social domains in a sample of 58 children with PTD. Each domain was rated on the extent to which the parents perceived that impairment was related to tics versus non-tic-related concerns. In …

A Latent Profile Analysis Of Age Of Onset In Pathological Skin Picking, Emily J. Ricketts, Ivar Snorrason, Katharina Kircanski, Jennifer R. Alexander, Hardian Thamrin, Christopher A. Flessner, Martin E. Franklin, John Piacentini, Douglas W. Woods

Psychology Faculty Research and Publications

Background

Pathological Skin Picking (PSP) may begin at any age, but the most common age of onset is during adolescence. Age of onset is a potentially useful clinical marker to delineate subtypes of psychiatric disorders. The present study sought to examine empirically defined age of onset groups in adults with PSP and assess whether groups differed on clinical characteristics.

Method

Participants were 701 adult respondents to an internet survey, who endorsed recurrent skin picking with tissue damage and impairment. Latent profile analysis (LPA) was conducted to identify subtypes of PSP based on age of onset. Then subgroups were compared on …

A Zero-Inflated Box-Cox Normal Unipolar Item Response Model For Measuring Constructs Of Psychopathology, Brooke E. Magnus, Yang Liu

Psychology Faculty Research and Publications

This research introduces a latent class item response theory (IRT) approach for modeling item response data from zero-inflated, positively skewed, and arguably unipolar constructs of psychopathology. As motivating data, the authors use 4,925 responses to the Patient Health Questionnaire (PHQ-9), a nine Likert-type item depression screener that inquires about a variety of depressive symptoms. First, Lucke’s log-logistic unipolar item response model is extended to accommodate polytomous responses. Then, a nontrivial proportion of individuals who do not endorse any of the symptoms are accounted for by including a nonpathological class that represents those who may be absent on or at some …

Comparing Procedures On The Acquisition And Generalization Of Tacts For Children With Autism Spectrum Disorder, Norma R. Schnell, Jason C. Vladescu, Tiffany Kodak, Casey L. Nottingham

Psychology Faculty Research and Publications

Generalization is a critical outcome for individuals with autism spectrum disorder (ASD) who display new skills in a limited range of contexts. In the absence of proper planning, generalization may not be observed. The purpose of the current study was to directly compare serial to concurrent multiple exemplar training using total training time per exemplar, mean total training time, and exposures to mastery across three children diagnosed with ASD. Additionally, we assessed the efficiency of presenting secondary targets in the antecedent and consequence portions of learning trials and evaluated generalization to tacts not associated with direct teaching. Results suggested that …

Differential 5-Year Brain Atrophy Rates In Cognitively Declining And Stable Apoe-Ε4 Elders, Dana A. Kelly, Michael Seidenberg, Katherine Reiter, Kristy A. Nielson, John L. Woodard, J. Carson Smith, Sally Durgerian, Stephen M. Rao

Psychology Faculty Research and Publications

Objective: The apolipoprotein E (APOE) ε4 allele is the most important genetic risk factor for late-onset Alzheimer’s disease. Many ε4 carriers, however, never develop Alzheimer’s disease. The purpose of this study is to characterize the variability in phenotypic expression of the ε4 allele, as measured by the longitudinal trajectory of cognitive test scores and MRI brain volumes, in cognitively intact elders. Method: Healthy older adults, ages 65–85, participated in a 5-year longitudinal study that included structural MRI and cognitive testing administered at baseline and at 1.5 and 5 years postenrollment. Participants included 22 ε4 noncarriers, 15 ε4 carriers who experienced …

Caregiver Behaviors Associated With Emotion Regulation In High-Risk Preschoolers, Christina Caiozzo, Kristen Yule, John H. Grych

Psychology Faculty Research and Publications

Children who witness violence are at risk for developing a range of developmental problems, including deficits in understanding and regulating. The ability to adaptively manage emotions is associated with children’s mental health and their social and academic competence; however, little is known about how parents of at-risk youth can foster the healthy development of emotion regulation. The current study aimed to identify specific parenting practices associated with adaptive emotion regulation in at-risk preschoolers. Multimethod, multi-informant data were collected from 124 caregiver-child dyads from Head Start programs. Results indicated that interparental aggression was negatively associated with caregivers’ and children’s emotion regulation, …

Interpersonal Behavior In Couple Therapy: Concurrent And Prospective Associations With Depressive Symptoms And Relationship Distress, Lynne M. Knobloch-Fedders, Stephanie J. Wilson

Psychology Faculty Research and Publications

Objective: This study investigated associations between couples’ interpersonal behavior, depressive symptoms, and relationship distress over the course of couple psychotherapy. Method: After every other session of Integrative Systemic Therapy (M = 13 sessions), N = 100 individuals within 50 couples rated their in-session affiliation and autonomy behavior using the circumplex-based Structural Analysis of Social Behavior Intrex. Concurrent and prospective associations of interpersonal behavior with depressive symptoms and relationship distress were evaluated via multivariate multilevel modeling using the Actor-Partner Interdependence Model. Results: An individual’s hostility, as well as the partner’s hostility, positively predicted an individual’s concurrent depressive symptoms and …

Validation Of The Registered Nurse Assessment Of Readiness For Hospital Discharge Scale, Kathleen L. Bobay, Marianne E. Weiss, Debra L. Oswald, Olga Yakusheva

Psychology Faculty Research and Publications

Background

Statistical models for predicting readmissions have been published for high-risk patient populations but typically focus on patient characteristics; nurse judgment is rarely considered in a formalized way to supplement prediction models.

Objectives

The purpose of this study was to determine psychometric properties of long and short forms of the Registered Nurse Readiness for Hospital Discharge Scale (RN-RHDS), including reliability, factor structure, and predictive validity.

Methods

Data were aggregated from two studies conducted at four hospitals in the Midwestern United States. The RN-RHDS was completed within 4 hours before hospital discharge by the discharging nurse. Data on readmissions and emergency …

Self-Esteem In Adults With Tourette Syndrome And Chronic Tic Disorders: The Roles Of Tic Severity, Treatment, And Comorbidity, Hilary Weingarden, Lawrence Scahill, Susanne Hoeppner, Alan L. Peterson, Douglas W. Woods, John T. Walkup, John Piacentini, Sabine Wilhelm

Psychology Faculty Research and Publications

Background

Tourette syndrome (TS) and chronic tic disorders (CTD) are stigmatizing disorders that may significantly impact self-esteem. Alternatively, comorbid psychiatric illnesses may affect self-esteem more than tics themselves. Extant research on self-esteem in TS/CTD is limited, has inconsistently examined the effect of comorbidities on self-esteem, and yields mixed findings.

Method

This study aimed to clarify the roles of tics versus comorbid diagnoses on self-esteem in a large, carefully diagnosed sample of adults with TS/CTD (N = 122) receiving 10 weeks of Comprehensive Behavioral Intervention for Tics (CBIT) or Psychoeducation and Supportive Therapy (PST).

Results

Baseline self-esteem did not differ …

The Benefits Of Adding A Brief Measure Of Simple Reaction Time To The Assessment Of Executive Function Skills In Early Childhood, Michael T. Willoughby, Clancy B. Blair, Laura J. Kuhn, Brooke E. Magnus

Psychology Faculty Research and Publications

Early childhood represents a period of rapid cognitive developmental change in executive function (EF) skills along with a variety of related cognitive processes, including processing speed. This leads to interpretational challenges in that children’s performance on EF tasks reflects more than EF skills per se. We tested whether the inclusion of a brief measure of simple reaction time (SRT) during EF assessments could help to partially address this challenge. Data were drawn from a cross-sectional convenience sample of 830 preschool-aged children. Individual differences in SRT were significantly associated with performance on all tasks (R²s = .09–.26); slower …

Patterns And Predictors Of Tic Suppressibility In Youth With Tic Disorders, Christine A. Conelea, Brianna Wellen, Douglas W. Woods, Deanna J. Greene, Kevin J. Black, Matthew Specht, Michael B. Himle, Han-Joo Lee, Matthew R. Capriotti

Psychology Faculty Research and Publications

Tic suppression is the primary target of tic disorder treatment, but factors that influence voluntary tic inhibition are not well understood. Several studies using the Tic Suppression Task have demonstrated significant inter-individual variability in tic suppressibility but have individually been underpowered to address correlates of tic suppression. The present study explored patterns and clinical correlates of reward-enhanced tic suppression in youth with tic disorders using a large, pooled dataset. Individual-level data from nine studies using the Tic Suppression Task were pooled, yielding a sample of 99 youth with tic disorders. Analyses examined patterns of tic suppressibility and the relationship between …

Minority Stress And Leukocyte Gene Expression In Sexual Minority Men Living With Treated Hiv Infection, Annesa Flentje, Kord M. Kober, Adam W. Carrico, Torsten B. Neilands, Elana Flowers, Nicholas C. Heck, Bradley E. Aouizerat

Psychology Faculty Research and Publications

Sexual minority (i.e., non-heterosexual) individuals experience poorer mental and physical health, accounted for in part by the additional burden of sexual minority stress occurring from being situated in a culture favoring heteronormativity. Informed by previous research, the purpose of this study was to identify the relationship between sexual minority stress and leukocyte gene expression related to inflammation, cancer, immune function, and cardiovascular function. Sexual minority men living with HIV who were on anti-retroviral medication, had viral load < 200 copies/mL, and had biologically confirmed, recent methamphetamine use completed minority stress measures and submitted blood samples for RNA sequencing on leukocytes. Differential gene expression and pathway analyses were conducted comparing those with clinically elevated minority stress (n = 18) and those who did not meet the clinical cutoff (n = 20), covarying reactive urine toxicology results for very …

The Role Of Acculturation Differences And Acculturation Conflict In Latino Family Mental Health, Kathryn E. Lawton, Alyson C. Gerdes, Theresa Lauer Kapke

Psychology Faculty Research and Publications

In order to help address the mental health disparities that exist for Latino families in the U.S., the current study sought to examine the acculturation–mental health link within the context of Latino families and to identify potential mechanisms for intervention to alleviate mental health problems in this population. Specifically, our goal was to examine how parent–adolescent acculturation differences were related to mental health in Latino adolescents and their parents and to understand the role of acculturation conflict and family functioning within Latino families. Participants included 84 adolescent–parent dyads recruited through bilingual middle schools. We found partial support for our hypothesis …

Examining The Links Between Challenging Behaviors In Youth With Asd And Parental Stress, Mental Health, And Involvement: Applying An Adaptation Of The Family Stress Model To Families Of Youth With Asd, Hillary Schiltz, Alana J. Mcvey, Brooke E. Magnus, Bridget Kathleen Dolan, Kirsten S. Willar, Sheryl Pleiss, Jeffrey S. Karst, Audrey Meyer Carson, Christina Caiozzo, Elisabeth M. Vogt, Amy V. Van Hecke

Psychology Faculty Research and Publications

Raising a child with autism spectrum disorder (ASD) poses unique challenges that may impact parents’ mental health and parenting experiences. The current study analyzed self-report data from 77 parents of youth with ASD. A serial multiple mediation model revealed that parenting stress (SIPA) and parental mental health (BAI and BDI-II) appears to be impacted by challenging adolescent behaviors (SSIS-PBs) and, in turn, affect parental involvement (PRQ), controlling for social skills (SSIS-SSs). Further, the study explored the malleability of parents’ mental health over the course of a social skills intervention, and provides modest evidence that parent depressive symptoms decline across intervention. …

Computerized Response Inhibition Training For Children With Trichotillomania, Han-Joo Lee, Flint M. Espil, Christopher C. Bauer, Stephan G. Siwiec, Douglas W. Woods

Psychology Faculty Research and Publications

Evidence suggests that trichotillomania is characterized by impairment in response inhibition, which is the ability to suppress pre-potent/dominant but inappropriate responses. This study sought to test the feasibility of computerized response inhibition training for children with trichotillomania. Twenty-two children were randomized to the 8-session response inhibition training (RIT; n = 12) or a waitlisted control (WLT; n = 10). Primary outcomes were assessed by an independent evaluator, using the Clinical Global Impression-Improvement (CGI-I), and the NIMH Trichotillomania Severity (NIMH-TSS) and Impairment scales (NIMH-TIS) at pre, post-training/waiting, and 1-month follow-up. Relative to the WLT group, the RIT group showed a higher …

Abnormal Perceptual Sensitivity In Body-Focused Repetitive Behaviors, David C. Houghton, Jennifer R. Alexander, Christopher C. Bauer, Douglas W. Woods

Psychology Faculty Research and Publications

Objective

Several compulsive grooming habits such as hair pulling, skin picking, and nail biting are collectively known as body-focused repetitive behaviors (BFRBs). Although subclinical BFRBs are common and benign, more severe and damaging manifestations exist that are difficult to manage. Researchers have suggested that BFRBs are maintained by various cognitive, affective, and sensory contingencies. Although the involvement of cognitive and affective processes in BFRBs has been studied, there is a paucity of research on sensory processes.

Methods

The current study tested whether adults with subclinical or clinical BFRBs would report abnormal patterns of sensory processing as compared to a healthy …

Neurocognitive Correlates Of Treatment Response In Children With Tourette's Disorder, Susanna W. Chang, Joseph F. Mcguire, John T. Walkup, Douglas W. Woods, Lawrence Scahill, Sabine Wilhelm, Alan L. Peterson, James Dziura, John Piacentini

Psychology Faculty Research and Publications

This paper examined neurocognitive functioning and its relationship to behavior treatment response among youth with Tourette's Disorder (TD) in a large randomized controlled trial. Participants diagnosed with TD completed a brief neurocognitive battery assessing inhibitory functions, working memory, and habit learning pre- and post-treatment with behavior therapy (CBIT, Comprehensive Behavioral Intervention for Tics) or psychoeducation plus supportive therapy (PST). At baseline, youth with tics and Attention Deficit Hyperactivity Disorder (ADHD) exhibited some evidence of impaired working memory and simple motor inhibition relative to youth with tics without ADHD. Additionally, a small negative association was found between antipsychotic medications and youth's …

Resilience Portfolios And Poly-Strengths: Identifying Protective Factors Associated With Thriving After Adversity, Sherry L. Hamby, John H. Grych, Victoria Banyard

Psychology Faculty Research and Publications

Objective: Interest in protective factors for adversity has burgeoned, but the set of examined protective factors remains limited and most studies have focused on a single or narrow set of adversities. Using the resilience portfolio model as a conceptual framework, this study seeks to identify promising protective factors for individuals exposed to violence and other adversities. We include strengths drawn from the positive psychology literature in addition to established protective factors. We also explore the utility of the concept of poly-strengths, or the number of different types of protective factors an individual has. Method: Participants were 2,565 adolescents and adults …

Estimating Hiv Medication Adherence And Persistence: Two Instruments For Clinical And Research Use, David A. Wohl, A. T. Panter, Christine Kirby, Brooke E. Magnus, Michael G. Hudgens, Andrew G. Allmon, Katie R. Mollan

Psychology Faculty Research and Publications

Antiretroviral therapy (ART) requires lifelong daily oral therapy. While patient characteristics associated with suboptimal ART adherence and persistence have been described in cohorts of HIV-infected persons, these factors are poor predictors of individual medication taking behaviors. We aimed to create and test instruments for the estimation of future ART adherence and persistence for clinical and research applications. Following formative work, a battery of 148 items broadly related to HIV infection and treatment was developed and administered to 181 HIV-infected patients. ART adherence and persistence were assessed using electronic monitoring for 3 months. Perceived confidence in medication taking and self-reported barriers …

Changes In Depressive Symptoms Among Adolescents With Asd Completing The Peers® Social Skills Intervention, Hillary Schiltz, Alana J. Mcvey, Bridget Kathleen Dolan, Kirsten S. Willar, Sheryl Pleiss, Jeffrey S. Karst, Audrey M. Carson, Christina Caiozzo, Elisabeth M. Vogt, Brianna D. Yund, Amy V. Van Hecke

Psychology Faculty Research and Publications

Depression is a common concern among people with autism spectrum disorder (ASD) and is often associated with social skills and relationship challenges. The present data, from a randomized controlled trial, examined the effect of PEERS^® on self-reported depressive symptoms via the Children’s Depression Inventory (CDI) among 49 adolescents with ASD. Findings revealed that many CDI subscale scores declined (p’s < 0.05) and were related to direct social contact on the Quality of Socialization Questionnaire at posttest (p’s < 0.05). Exploratory analyses uncovered that suicidality was less evident following PEERS^®. Findings support the notion that social functioning and depression may be intimately intertwined in ASD; therefore, bolstering social skills in ASD may positively influence other domains of functioning, including mental health.

Emotion Regulation Deficits In Persons With Body-Focused Repetitive Behavior Disorders, Jennifer R. Alexander, David C. Houghton, Christopher C. Bauer, Heather C. Lench, Douglas W. Woods

Psychology Faculty Research and Publications

Background

Conceptualizations of emotion dysregulation (ED) and body-focused repetitive behavior disorders (BFRBDs) imply that ED may be a central component of BFRBDs as well as a factor that distinguishes BFRBDs from non-impairing, subclinical body-focused repetitive behaviors (BFRBs). The current study empirically tested these observations.

Methods

One hundred thirty-eight undergraduates (of 1900 who completed a screening survey) completed self-report measures assessing four emotion regulation (ER) deficits hypothesized to underlie ED (alexithymia, maladaptive emotional reactivity, experiential avoidance, and response inhibition when distressed); 34 of these participants had BFRBDs, 64 had subclinical BFRBs, and 42 were unaffected by BFRBs.

Results

Results indicated that …

A Multicenter Examination And Strategic Revisions Of The Yale Global Tic Severity Scale, Joseph F. Mcguire, John Piacentini, Eric A. Storch, Tanya K. Murphy, Emily J. Ricketts, Douglas W. Woods, John T. Walkup, Alan L. Peterson, Sabine Wilhelm, Adam B. Lewin, James T. Mccracken, James F. Leckman, Lawrence Scahill

Psychology Faculty Research and Publications

Objective To examine the internal consistency and distribution of the Yale Global Tic Severity Scale (YGTSS) scores to inform modification of the measure.

Methods This cross-sectional study included 617 participants with a tic disorder (516 children and 101 adults), who completed an age-appropriate diagnostic interview and the YGTSS to evaluate tic symptom severity. The distributions of scores on YGTSS dimensions were evaluated for normality and skewness. For dimensions that were skewed across motor and phonic tics, a modified Delphi consensus process was used to revise selected anchor points.

Results Children and adults had similar clinical characteristics, including tic symptom severity. …

Stress And Quality Of Life Among Parents Of Children With Congenital Heart Disease Referred For Psychological Services, Astrida S. Kaugars, Clarissa Shields, Cheryl Brosig

Psychology Faculty Research and Publications

Objective

The study examined parent stress and health‐related quality of life (HRQOL) among families of children with congenital heart disease (CHD) referred for psychological services.

Methods

Parents of 54 children (85% boys) aged 3 to 13 (M_age = 7.48, SD = 2.38) completed measures to assess parenting stress (Parenting Stress Index – Short Form; Pediatric Inventory for Parents) and the PedsQL Family Impact Module. Medical information was retrieved from medical record review.

Results

Half of parents of children with single ventricle anatomy had clinically significant levels of parenting stress. Parents of children with single ventricle anatomy reported more …

Intersectionality Research Within Latinx Mental Health: Conceptual And Methodological Considerations, Lucas Torres, Felicia Mata-Greve, Claire Maria Bird, Erick Herrera Hernandez

Psychology Faculty Research and Publications

Intersectionality considers the meaning and consequences associated with multiple identities along interlocking systems of disadvantage and inequality (Cole, 2009; Crenshaw, 1991). In recent years, there has been increasing attention on examining the mental health outcomes associated with membership in multiple marginalized groups. Unfortunately, intersectionality research examining the unique experiences of Latinx groups remains scarce. The current article reviews theoretical and methodological considerations regarding intersectionality research within Latinx mental health. From a theoretical perspective, intersectionality brings a series of questions regarding the epistemological approaches to studying psychological phenomena. This, in turn, influ- ences the methodological strategies used to examine these processes. …

Selection And Implementation Of Skill Acquisition Programs By Special Education Teachers And Staff For Students With Autism Spectrum Disorder, Tiffany Kodak, Tom Cariveau, Brittany A. Leblanc

Psychology Faculty Research and Publications

The present investigation examined special education teachers’ selection and use of teaching strategies for receptive identification training with children with autism spectrum disorder (ASD) in their classrooms. Teachers first responded to a survey in which they provided examples of receptive identification tasks taught in their classrooms, rated the efficacy of teaching strategies, described how they determined whether skills were mastered, listed any assessments they conducted to identify relevant prerequisite skills prior to receptive identification training, described how they selected teaching strategies for use in their classrooms, and listed their years of experience as a teacher and working with children with …

Who Believes In A Male God? Ideological Beliefs And Gendered Conceptualizations Of God, Simon Howard, Debra L. Oswald, Mackenzie S. Kirkman

Psychology Faculty Research and Publications

Recent studies have explored whether certain conceptualizations of God are associated with various attitudes and beliefs. In the current study, we examined the relationship between gendered God concepts and the belief that God is involved in one’s life and religious-related rigid ideologies (i.e., religious fundamentalism and right-wing authoritarianism [RWA]). Across two studies, one conducted with religious students at a Jesuit university and the other with a national sample, we found that individuals who believed God to be male were more likely to believe that God had more control and involvement in their life, had higher levels of religious fundamentalism and …

Sequential Analysis Of Affirmation And Disclosure In Couple Interaction: Associations With Relational Uncertainty And Relationship Distress, Lynne M. Knobloch-Fedders, Kelly Quirk

Psychology Faculty Research and Publications

No abstract provided.

Benchmarking Treatment Response In Tourette’S Disorder: A Psychometric Evaluation And Signal Detection Analysis Of The Parent Tic Questionnaire, Madeline M. Rasch, Douglas W. Woods, Matthew W. Specht, John T. Walkup, Lawrence Scahill, Sabine Wilhelm, Alan L. Peterson, John Piacentini

Psychology Faculty Research and Publications

This study assessed the psychometric properties of a parent-reported tic severity measure, the Parent Tic Questionnaire (PTQ), and used the scale to establish guidelines for delineating clinically significant tic treatment response. Participants were 126 children ages 9 to 17 who participated in a randomized controlled trial of Comprehensive Behavioral Intervention for Tics (CBIT). Tic severity was assessed using the Yale Global Tic Severity Scale (YGTSS), Hopkins Motor/Vocal Tic Scale (HMVTS) and PTQ; positive treatment response was defined by a score of 1 (very much improved) or 2 (much improved) on the Clinical Global Impressions – Improvement …

Therapist Self-Disclosure And Immediacy: A Qualitative Meta-Analysis, Clara E. Hill, Sarah Knox, Kristen Pinto-Coelho

Psychology Faculty Research and Publications

We review definitions and provide case examples of therapist self-disclosure (TSD) and immediacy (Im). We then present a qualitative meta-analysis of 21 studies that examined the subsequent process following TSD and Im in psychotherapy (excluding analogue and correlational studies). Across the 21 studies, the most frequent subsequent processes were enhanced therapy relationship, improved client mental health functioning, gains in insight, and overall helpfulness, suggesting that most often TSD and Im were followed by positive and beneficial therapeutic processes. In additional analyses, TSD was associated more often with improved mental health functioning, overall helpfulness, and enhanced therapy relationships, whereas Im was …