Which of the following is descriptive of rational-emotive-behavioral counseling?

Rationale for Therapy

The many reasons for establishing periodontal health before performing restorative dentistry include the following52:

Periodontal treatment is undertaken to ensure the establishment of stable gingival margins before tooth preparation. Noninflamed, healthy tissues are less likely to change (e.g., shrink) as a result of subgingival restorative treatment or postrestoration periodontal care.28,29 In addition, tissues that do not bleed during restorative manipulation allow for a more predictable restorative and aesthetic result.22,23

Certain periodontal procedures are designed to provide for adequate tooth length for retention, access for tooth preparation, impression making, tooth preparation, and finishing of restorative margins in anticipation of restorative dentistry.22,47 Failure to complete these procedures before restorative care can add to the complexity of treatment and introduce unnecessary risk for failure.22

Periodontal therapy should antecede restorative care because the resolution of inflammation may result in the repositioning of teeth46 or in soft tissue and mucosal changes.20,48 Failure to anticipate these changes may interfere with prosthetic designs planned or constructed before periodontal treatment.

Traumatic forces placed on teeth with ongoing periodontitis may increase tooth mobility, discomfort, and possibly the rate of attachment loss.9 Restorations constructed on teeth free of periodontal inflammation, synchronous with a functionally appropriate occlusion, are more compatible with long-term periodontal stability and comfort (seeChapters 18 and55).

Quality, quantity, and topography of the periodontium may play important roles as structural defense factors in maintaining periodontal health. Orthodontic tooth movement and restorations completed without the benefit of periodontal treatment designed for this purpose may be subject to negative changes that complicate construction and future maintenance.55

Successful aesthetic and implant procedures may be difficult or impossible without the specialized periodontal procedures developed for this purpose.

Learning Box 69.1

Periodontal treatment is undertaken to ensure the establishment of stable gingival margins before tooth preparation. Noninflamed, healthy tissues are less likely to change (e.g., shrink) as a result of subgingival restorative treatment or postrestoration periodontal care. In addition, tissues that do not bleed during restorative manipulation allow for a more predictable restorative and aesthetic result.

II. Rational Emotive Behavior Therapy Techniques

To help people specifically achieve and maintain a thoroughgoing antimusturbatory basic outlook, REBT teaches them to use a number of cognitive, emotive, and behavioral methods. It helps them gain many insights into their disturbances, but emphasizes three present-oriented ones:Insight No. 1: People are innate constructivists and by nature, teaching, and, especially, self-training they contribute to their own psychological dysfunctioning. They create as well as acquire their emotional disabilities—as the ABC theory of REBT notes.

Insight No. 2: People usually, with the “help” and connivance of their family members, first make themselves disturbed when they are young and relatively foolish. But then they actively, although often unconsciously, work hard after their childhood and adolescence is over to habituate themselves to dysfunctional thinking, feeling, and acting. That is mainly why they stay disturbed today. They continue to construct dysfunctional Beliefs.

Insight No. 3: Because of their natural and acquired propensities to strongly choose major goals and values and to insist, as well as to prefer, that they must achieve them, and because they hold these self-defeating beliefs and feelings for many years, people firmly retain and often resist changing them. Therefore, there usually is no way for them to change but work and practice—yes, work; yes, practice—for a period of time. Heavy work and practice for short periods of time will help; so brief rational emotive behavior therapy can be useful. But for long-range gain, and for clients to get better rather than to feel better, they require considerable effort to make cognitive, emotive, and behavioral changes.

REBT clients are usually shown how to use these three insights in the first few sessions of psychotherapy. Thus if they are quite depressed (at point C) about, say, being rejected (at point A) for a very desirable job, they are shown that this rejection by itself did not lead to their depression (C). Instead they mainly upset themselves with their musturbatory Beliefs (B) about the Adversity (A). The therapist explores the hypothesis that they probably took their desire to get accepted and elevated it into a demand—for example, “I must not be rejected! This rejection makes me an inadequate person who will continually lose out on fine jobs!”

Second, clients are shown—using REBT Insight No.2—that their remembering past Adversities (A), such as past rejections and failures, does not really make them depressed today (C). Again, it is largely their Beliefs (B) about these Adversities that now make them prone to depression.

Third, clients are shown that if they work hard and persistently at changing their dysfunctional Beliefs (B), their dire needs for success and approval, and return to mere preferences, they can now minimize their depressed feelings—and, better yet, keep warding them off and rarely falling back to them in the future. REBT enables them to make themselves less disturbed and less disturbable.

Nonpharmacologic Therapy

Discussions about the “reality” of CFS are decidedly unhelpful and often insulting to patients. Similarly, framing the illness in a manner that is inconsistent with the patient's perceptions (e.g., as “depression” in the absence of formal psychiatric criteria) is likely to evoke resistance and nonadherence. The best approach is the one that is most consistent with current understanding of CFS: to recognize and validate the patient's symptoms as part of an idiopathic syndrome. In doing so, it is essential to educate the patient about the unexplained nature of the fatiguing illness and to correct any misinformation that the patient may have about its cause or treatment. This approach allows the physician to enlist the patient's support in pursuing the rational management agenda.

All patients should be counseled regarding exercise and sleep hygiene. Many patients have significant disruptions in their sleep patterns that should be corrected gradually. Daytime napping should be limited or avoided altogether because this behavior may further disrupt nighttime sleep quality. Melatonin is a popular over-the-counter sleep remedy used by many patients; however, the rationale for this therapy is unclear, given that CFS patients have normal levels and timing of endogenous melatonin secretion.161

Although some patients report relief of symptoms with dietary alterations, there is little reliable experimental evidence to inform changes in diet. A recent RCT showed that a low-sugar, low-yeast diet, recommended by some, was no more efficacious in relieving fatigue or improving quality of life than simple, healthy eating.162 Highly restrictive diets that may impair general nutrition should be discouraged.

Among psychological therapies, cognitive-behavioral therapy (CBT) is considered the most effective modality in CFS patients. This approach involves a restructuring of the patient's beliefs concerning the causes of the illness and an objective assessment of the symptoms and disabilities. A 2008 meta-analysis reported successful outcome in about half of the patients entering therapy and a mean drop-out rate of 16%. The authors concluded that this modality was moderately effective.163 The development and use of an online CBT program for Dutch adolescents likely improves the cost-effectiveness of this method as well. A randomized, open-label trial in the Netherlands showed that an Internet-based CBT program resulted in eightfold likelihood of recovery than randomization to usual care in a tertiary treatment center during a 6-month treatment period.164 A long-term follow-up study (mean follow-up, 2.7 years) showed that the eventual recovery rate was similar in both CBT and “usual care” subjects, but the CBT-assigned subjects achieved a faster and sustained recovery after completing the online program.165

Rational emotive behavior therapy (REBT) was originated in 1955 as a pioneering cognitive-experiential-behavioral system of psychotherapy. It is heavily cognitive and philosophic, and specifically uncovers clients' irrational or dysfunctional beliefs and actively-directively disputes them. But it also sees people's self-defeating cognitions, emotions, and behaviors as intrinsically and holistically connected, not disparate. It holds that they disturb themselves with disordered thoughts, feelings, and actions, all of which importantly interact with each other and with the difficulties they encounter in their environment. Therefore, with emotionally and behaviorally disturbed people, REBT employs a number of thinking, feeling, and action techniques that are designed to help them change their self-defeating and socially sabotaging conduct to self-helping and socially effective ways. REBT theorizes that virtually all humans consciously and unconsciously train themselves to be to some degree emotionally disturbed. Therefore, with the help of an effective therapist and/or with self-help materials, they can teach themselves to lead more satisfying lives—if they choose to do so and work hard at modifying their thinking, feeling, and behaving.

II.F. Cognitive Theory Elaborations That Affect Cognitive Therapies

Although CT and REBT may rightly claim a place as mainstream components of behavior therapy, the groundswell that resulted in the widespread acceptance of these approaches had been set in motion earlier, aside from the initial “behavioral” interventions described by Cautela. Notable here is self-efficacy theory by Bandura. Self-efficacy refers to a person's belief in the extent that their actions influence the environment in ways that are advantageous. These beliefs are said to causally contribute to behavior as well as emotional experience. This is also the central position of the cognitive therapies. This assertion has led to considerable debate within the field, and is not yet resolved. The procognitive side of the argument strongly suggests that observational learning rests on an assumption that even without direct contact with contingencies higher-order organisms learn, which implies cognition. Cognitive theorists have also suggested that radical behaviorists discount cognition despite references to “private events” and that cognition represents a plausible area of investigation within the broader domain of CBT. The behavioral position suggests that cognitions (all private events) are epiphenomena representing a higher-order class of behavior. Further, in response to the concern over mere labeling, behaviorists have argued that cognitions exist as correlates of behavior. It has been said that the move to cognitive analyses has always been part of psychological assessment but it should not occur at the cost of traditional behavioral assessment. Cognitive variables are private events and therefore are essentially unknowable by an observer because of measurement problems. Although the controversy continues regarding whether cognition represents a causal link between behavior and consequences, researchers examining treatment components for specific disorders have embraced self-efficacy. For example, in 1985 Marlatt and Gordon outlined a cognitive-behavioral theory of treatment for substance use that has gained prominence. Since that time, self-efficacy has figured prominently in several variants of cognitive-behavioral therapy for smoking, obesity, depression, anxiety disorders, and marital distress.

Unconscious Processing in Psychological Treatments

Psychological treatments can be rank ordered by how much unconscious processing they admit to. Cognitive therapy and rational emotive behavior therapy acknowledge the least amount of unconscious processing; i.e., are perhaps the most conscious-centric contemporary psychological interventions. They assume that cognitive biases cause all psychological distress and aim to help people think differently about themselves and other people. This was also the aim of Heinz Hartmann’s (1939/1958) Ego psychology. Cognitive bias modification (CBM) is a relatively new CBT that makes therapeutic use of the dot-probe task, described below, and related methods. Hallion and Ruscio (2011) reported results of a meta-analysis regarding cognitive bias modification for the treatment of anxiety and depression. They reported that CBM produced a medium effect (g = 0.49) over 45 studies covering 2,591 participants that was stronger for interpretation biases (g = 0.81) than for attention biases (g = 0.29). CBM was found to have a small effect on anxiety and depression (g = 0.13).

Behavior theory says little about conscious or unconscious processing. Applied behavior analysis (ABA) applies principles of operant conditioning to the amelioration of behavior problems. These principles were developed in the laboratory on animals that presumably rely more on unconscious processing than humans do. Reinforcers strengthen behaviors, but people are unaware of the mediating neuroscience mechanisms. Thus, while arranging reinforcement contingencies is the result of conscious planning, the mechanism of behavior change remains outside of awareness. Exposure treatment seems to entail a fair amount of unconscious processing, because during the actual exposure trials the client mainly focuses their attention on what they are experiencing rather than on the change process. Exposure therapy is facilitated by d-cycloserine (DCS) that activates pharmacological mechanisms of which clients are completely unaware.

Second Session

1.

Review of homework

Practice of rapid relaxation

Analysis of anxiety in social situations

Cognitive restructuring: explanation of the A-B-C model of the REBT

Homework assignment

Review of homework. Approximately 20 min of each session should be devoted to review homework assignments of the previous week. It is described what each individual did, homework done correctly is reinforced and any difficulties the patients has had are clarified.

Rapid relaxation practice. Teach group members how to relax in a shorter period of time. Muscles are not tensed anymore, but only relaxed. The sequence of relaxation is similar to the previous session.

Analysis of anxiety in social situations. Go over some possible “myths” about anxiety that the therapist may need to correct. For example (Walen, 1985):

Anxiety is dangerous: I could have a heart attack

I could lose control or blow up in some way

It is a sign of weakness

The anxiety attack will never pass

Explain to the patient that anxiety has a “lifecycle” and that after reaching its peak, it will begin to subside. Furthermore, a little anxiety can be good in some situations. However, a large part of daily tension is unnecessary.

In order to recognise tension more easily, the patient may be aware of certain “symptoms” which may indicate the presence of anxiety. Table 2.1 lists some of these symptoms which are indicators of the presence of anxiety.

Table 2.1. Possible Symptoms of Expression of Anxiety or Nervousness

Then the group is taught how to use the Subjective Units of Disturbance Scale (SUDS) in the following way (Cotler & Guerra, 1976; Galassi & Galassi, 1977).

The SUD scale is used to communicate the level of anxiety subjectively experienced. In using the scale, you will have to rate your anxiety level from 0, completely relaxed, to 100, a state of panic.

Imagine when you are completely relaxed and calm. For some people this occurs whilst resting, taking a nice warm bath, or reading a good book. For others, it happens when they are walking on the beach or floating in the water. Give a “0” rating for how you feel when you are at your most relaxed.

Next, imagine a situation in which you experience extreme anxiety, a state of panic. Imagine feeling extremely tense and nervous. Maybe in this situation your hands feel cold and tremble. You may feel dizzy or flushed, or you may feel awkward. For some people, the situations in which they feel most nervous may be when a person close to them has had an accident, when there is excessive pressure on them (exams, work, etc.); or when they speak in front of a group. Give a rate of “100” for how you feel in this situation. You have already identified the two poles of the SUD Scale. Imagine the entire scale (like a ruler) that goes from “0” SUDS, completely relaxed, to “100” SUDS, very nervous, in panic.

051015… 50…859095100Completelyrelaxed Stateofpanic

Now you are familiar with the entire scale so that you can rate your level of anxiety. To practice using this scale, write down your SUDS rating right now.

You can use the SUDS rating to evaluate social situations that you encounter in real life. The relaxation method that you are learning will help to reduce your SUDS rating. Experiencing high levels of anxiety is uncomfortable to most people. Also, anxiety can prevent you from saying something you want to and can interfere with the way in which you get your message across.

The extent to which you will feel capable of reducing your SUDS scores in any kind of situation will depend upon a series of factors, including the level of anxiety which you generally experience, the SUDS rating you initially had, what type of behaviour is required, and the person to whom you direct your comment. We do not think that your goal should be to reach a 0 or 5 in every situation. Your goal will be to reduce your SUDS level to a point where you feel comfortable enough to express yourself.

To practice using the SUD scale, a series of situations can be described. For each situation, listen to the description of the scene and then imagine what is happening to you in this situation. After imagining the situation, write down the amount of anxiety (SUDS level) that you feel. Finally, if you were nervous or tense whilst imagining the scene, try concentrating on the parts of your body where you feel most anxiety (see Table 2.1). Did your stomach feel tense? Did you have a knot in your throat? Did you have cold or sweaty hands? Did you have a headache? Did your eyelids twitch? If you locate the area or areas where you feel most tense, you can use relaxation methods better.

For homework, the subject is given a self-report form where they have to identify and register a brief description of the situations which take place in their life and which cause them different levels of relaxation and anxiety. Along with the brief description of the situation, the patient is asked to describe their physical symptoms (see Table 2.1). The SUD ratings are already marked down on the page in increments of 10 points, so that the patient uses the whole scale, to 100 points. During the time they use the self-report sheet, the patient has to describe a situation which causes 0 to 9 anxiety and another which falls within the 10-19 range, etc. (see Table 2.2)

Table 2.2. Self-Monitoring Form of Subjective Units of Disturbance (SUDS)

The evaluation of the different levels of anxiety produced by different situations can serve several purposes. For example, asking individuals to register their anxiety level during interactions makes them think and concentrate. Thinking and concentrating is, in part, incompatible with anxiety. As such, it is likely that the person’s anxiety level will be reduced. Also, constantly checking the SUD rating during interpersonal interactions makes the subjects more aware of situations in which they repress their emotions and do not say or do anything about it.

It is explained to the patients that symptoms of anxiety are a consequence of negative cognitive stimulation and of avoidance behaviours, as well as subjective interpretation of the latter. It is explained to them that sometimes even using relaxation, some anxiety symptom(s) will occur (e.g. blushing, sweating, etc.). In these cases, they should stop fearing these responses and learn to tolerate them in order to eliminate them. Tell them that, paradoxically, to pass an exam we have to stop worrying about failing, to stop anxiety we have to stop worrying about anxiety and put up with it… Understanding of these facts is a great help in general for increasing tolerance and, as a result, diminishing the frequency of the appearance of these physiological responses.

Cognitive restructuring: introducing the REBT fundamentals. One way of introducing the individual to the rational emotive behaviour therapy (REBT), discovering defence mechanisms, showing how feelings are influenced by thinking, realising that a large part of these thoughts is automatic, is the following task: Ask groups members to sit down, to close their eyes, take deep breaths through their nose, hold it for a while and slowly breathe out through their mouth. Then give them the following instructions (Wessler, 1983):

I’m going to ask you to think of some secret, something about yourself that you normally wouldn’t tell to anyone else. It might be something you’ve done in the past, something you are doing now in the present. Some secret habit or physical characteristic (Pause). Are you thinking about it?(Pause) Good. Now I’m going to ask someone to tell the group what they have thought of… to describe it in some detail (Short pause) But since I know that everyone would want to do this, and we don’t have enough time to get everyone in, I’ll select someone (Pause – looking around the group) Yes, I think I have someone in mind (Pause). But before I call on that person, let me ask, what are you experiencing right now? (p. 49).

Usually people feel a high level of anxiety (if they have really gone through the exercise), which can be quantified by asking the subjects their SUDS rating. At this moment, the therapist shows the group that it is thinking about doing something, not doing it, what leads up to their feelings. Then, the therapist asks about the kinds of thoughts that led up to these feelings.

This exercise can be used to introduce individuals to the fundamentals of rational emotive behaviour therapy. For Ellis, anti-scientific or irrational thought is the main cause of emotional disturbance, since, consciously or unconsciously, the person chooses to become neurotic, with their unrealistic and illogical way of thinking (Ellis & Lega, 1993; Lega, Caballo & Ellis, 1997). Socially inadequate behaviour may stem from irrational or incorrect thought, from excessive or deficient emotional reactions to specific stimuli, and from patterns of dysfunctional behaviour. What we usually point out as our emotional reactions in certain situations are mainly caused by our conscious and/or automatic evaluations and suppositions. So, we feel anxiety not at the objective situation, but at our own interpretation of the situation. The ABC model of rational emotive behaviour therapy (see Figure 2.2) works in the following way (Lega, 1991; Lega et al., 1997): The A or activating event (specific activity or situation) does not directly and automatically produce C or consequences [which can be emotional (eC) and/or behavioural (bC)], otherwise, everyone would react identically to the same situation. “C” is caused by an interpretation of “A”, that is, by beliefs (B) which we generate about the situation. If “B” is functional, logical and empirical, it is considered “rational” (rB). If, on the other hand, it hampers normal functioning of the individual it is “irrational” (iB). The main method of replacing irrational beliefs (iB) with rational ones (rB) is called dispute or debate (D) and, basically, is an adaptation of the scientific method to daily life, a method through which hypothesis and theories are questioned to determine their validity. Science is not simply the use of logic and data to verify or reject a theory. Its most important aspect consists of constant revision and change of theories and the attempt to replace them with more valid ideas and useful conjectures. It is flexible rather than rigid, open-minded instead of dogmatic. It strives for a greater truth, but not for a perfect or absolute truth. It sticks to data and real facts (which can change at any moment) and to logic thought (which does not contradict itself by simultaneously upholding two opposite points of view). It also avoids rigid thinking patterns, such as “all-or-nothing” or “one or the other”, and accepts that, in general, reality has two sides and is made up of contradictory events and characteristics. Irrational thinking is dogmatic and dysfunctional and the individual evaluates him/herself, others, and the world in a rigid way (Ellis & Lega, 1993; Lega, 1991; Lega et al., 1997). These evaluations are couched via absolutistic demands, in the form of dogmatic “musts”, “skoulds”, and “have to’s” (instead of using probable or preferential concepts), generating dysfunctional emotions or behaviours which interfere with the successful pursuit of personal goals. From these absolutistic thinking, three conclusions are derived: (1) Awfulizing, which is the tendency to focus excessively on the negative nature of an event; (2). Low frustration tolerance or “I cant-stand-it-itis”, which is the tendency to exaggerate the discomfort of a situation and (3) Damnation which is the tendency to evaluate oneself or others as “totally bad”, compromising their value as people due to their behaviour. Ellis & Lega (1993) point out that learning to think rationally consists of applying the main rules of the scientific method to the way of seeing oneself, others and life. These rules are:

It is better to accept what is going on in the world as “reality”, even if we do not like it and try to change it.

In science, theories and hypothesis are postulated in a logical and consistent way, avoiding important contradictions (as well as false or unrealistic “data”.)

Science is flexible, nonrigid. It does not uphold something in an unconditional or absolute way.

Science does not include the concept of “deservingness” or “undeservingness”, nor deifies people (or things) for their “good” acts or damns them for their “bad” behaviour.

Science has no absolute rules about behaviour and human affairs, but it can help people to reach their goals and to be happy without offering any guarantees (Ellis & Lega, 1993).

Some of the most common irrational thoughts in human beings which Ellis recently summarised into the three conclusions we have just pointed out (e.g., Lega, 1991; Lega et al., 1997; Ellis, 1994), are the following (Ellis & Harper, 1975):

I must have love and approval from all the people significant to me.

I must prove thoroughly competent, adequate and achieving, or at least, must have competence or talent in some important area.

When people act obnoxiously and unfairly, they must be blamed and damned, and be considered as bad, wicked, or rotten.

It is awful and catastrophic when things do not go the way I would like them to.

Emotional misery comes from external pressures and people have little ability to control or change their feelings.

If something seems dangerous or fearsome, I must preoccupy myself with and make myself anxious about it.

It is easier to avoid confronting many life difficulties and responsibilities than undertake more rewarding forms of self-discipline.

People and things should turn out better than they do and I must view it as awful and horrible if I do not find good solutions to life’s hard realities

I can achieve happiness by inertia and lack of action or by passively and uncommittedly “enjoying myself”.

The application of the rules of the scientific method to challenge irrational thoughts is one of the key points of rational-emotive behaviour therapy. For instance, a patient with generalised social phobia thinks his co-workers “do not like him”; after being trained in the detection and analysis of these ideas (see later), they are able to recognise that the first irrational idea underlies this irrational thought (“I must be loved and approved by all the people significant to me”). Disputing such an idea could have the following steps (Ellis & Lega, 1993):

Conclusion (“awfulizing”)

Is this belief realistic and factual? (No, since there is no law which states that I have to be approved by people whom I find important;

Is this belief logical? (No, just because I find certain people important it does not follow that they must approve of me).

Is this belief flexible and unrigid (No, because it holds that under all conditions and at all the time people whom I find must approve of me, which is quite inflexible;

Do this belief prove that I “deserve” something? (No. It cannot prove that there is a rule of the universe they ought to, have to, and must approve of me even if I act nicely towards them; and

Does this belief show that I will be happy, I will act properly and will obtain good results? No, to the contrary. It does not matter how hard I try to get people to approve of me, I can easily fail – and if I then think that they have to like me, I will probably feel depressed).

Thinking about “always trying to get along with everyone”, of “having to always be approved of in an unconditional way by those around you” is very typical of individuals with generalised social phobia, so that any kind of minor criticism from others can cause anxiety symptoms to appear. These individuals are particularly sensitive to any kind of situation or commentary involving discomfort, disapproval or disagreement by others. These individuals tend to exaggerate and dramatise these comments, eliciting a maladaptive behavioural reaction, being aggressive or defensive, or clumsy (as Trower & Turland, 1984, describe it) or using avoidance or escape behaviours.

Homework Assignment. With the self-monitoring form of Table 2.2 group members have to select situations which have a subjective level of anxiety and which fall into everyone of the intervals indicated on the self-monitoring sheet. Each individual practices rapid relaxation every day at home. They also learn more about REBT with the appropriate reading (e.g., Lega et al., 1997).

Scientific Base

Constructs that are used as building blocks for the Behavioral/Cognitive-Behavioral conceptual model of practice are derived from behavioral psychology, particularly B.F. Skinner's operant conditioning theory, cognitive and cognitive-behavioral principles, including Ellis's Rational Emotive Behavior Therapy, Beck's Cognitive Therapy, Bandura's Cognitive Social Learning Theory, and the information-processing theory.** These psychological theories are discussed in detail in Chapter 3. In this chapter, we will present a summary of the theoretical core of the conceptual practice model, as gleaned from occupational therapy literature.

Affect: Anxiety and Self-Confidence

As identified in the previous section of the chapter, self-talk has been central to cognitive and cognitive-behavioral interventions for cognitive and emotional disorders, and behavior in general (Cognitive Behavior Therapy, Meichenbaum, 1977; Rational Emotive Behavior Therapy, Ellis, 1976). More emphatically Bernard, Ellis, and Terjensen (2006) identified the empowering aspect of self-talk on emotions in general and anxiety reduction in particular. Meichenbaum (1977) argued that self-statements will bring more adaptive thoughts and lead to more effective coping behavior under anxiety-inducing situations. In sport, performance anxiety and its treatment, through regulation of intensity or restructuring, is an issue of particular interest at both the applied and the research spectrums. Although self-talk has been identified as a potential strategy for reducing anxiety, research has been scarce.

In an intervention study with young tennis players, Hatzigeorgiadis, Zourbanos, Mpoumpaki, and Theodorakis (2009) found that the use of motivational self-talk following a 3-day self-talk training intervention resulted in improved performance and self-confidence, when performing under anxiety-inducing conditions. Importantly, a significant effect was identified for cognitive anxiety and a marginal effect for somatic anxiety, with participants of the interventions group reporting lower levels of anxiety than those of a control group. Further empirical evidence regarding effects of self-talk on anxiety, but also on emotion regulation in general, will strengthen our confidence for the popular, through anecdotal reports, belief regarding the role of self-talk for anxiety regulation, thus providing a basis for the mediating role of emotion regulation in the self-talk performance relationship.

10.05.3.3 Games for Prevention and Promotion

Few trials have explicitly tested serious games or gamification for prevention of mental health problems or promotion of good mental health. We identified one systematic review of serious games and commercial video games for treatment or prevention of child and adolescent disorders (Zayeni et al., 2020), which included five studies seeking to prevent emotional disorders, anxiety or depression among healthy children or adolescents or those with subclinical symptoms. Two were large studies trialling Rational Emotive Behavior Therapy (REBT) or CBT delivered in a video game format and the remaining three used two different programmes that incorporated biofeedback in combination with other mechanisms; each reported gains on outcome measures.

David and colleagues' study (David et al., 2019) of 165 healthy 10–16 year olds found that those in a standalone therapeutic video game condition had significant reduction in emotional symptoms and depressed mood and improvement in emotion regulation. The game involved a superhero and friends to help children challenge beliefs, based on Rational Emotive Behavior Therapy (REBT). In a mechanisms of change analysis, the authors reported that the gains were due to changes in irrational beliefs and proposed that, among this sample of children who had previously been exposed to REBT, the superior results in the gamified condition (versus a non-gamified condition) may have been due to the use of novel, game-based tools.

A revised version of SPARX (Fleming et al., 2019b), aimed at adolescents without clinical diagnoses, was effective for the prevention of depressive symptoms at 6 month (but not 18 month) follow up in a cluster randomised controlled trial of 540 adolescents (Perry et al., 2017).

Two studies of Mindlight, which uses storyline, CBT strategies and EEG biofeedback training, reported significant positive effects for anxiety prevention, and found that the game was not inferior to CBT in preventing anxiety disorders among children with elevated symptoms (Schoneveld et al., 2018). Another serious game, which used biofeedback on heart rate variability, was tested among adolescents with elevated symptoms of anxiety. The authors reported significant reductions in anxiety symptoms among participants in both the serious game condition and the commercial video game control condition (Scholten et al., 2016).

Trials comparing serious games and gamification with non-game based computerized interventions were lacking.