Procrastination is highly prevalent among university students and associated with substantial impairments in well-being and functioning. This randomized controlled trial examined the efficacy of two single-session interventions (SSIs) - one based on Cognitive Behavioural Therapy (CBT) and one on Acceptance and Commitment Therapy (ACT) - for reducing procrastination and tested the role of outcome expectations and experimentally induced expectation (in)congruence. A total of 151 students with recurrent procrastination and a currently postponed task were randomly assigned to a CBT-SSI, ACT-SSI, or a no-intervention control group. Interventions (approximately 60 minutes) were delivered face-to-face and preceded by a videotaped ACT- or CBT-based treatment rationale to manipulate expectation congruence. Assessments took place at baseline, post-intervention, and 2-week follow-up. The primary outcome was state procrastination (APSI-d); secondary outcomes included APSI-d Anxiety and Doubt and Task Aversion, depressive symptoms (PHQ-9), psychological flexibility (CompACT-8), perceived improvement and improvement expectations (G-EEE). Linear mixed models showed a substantial time x condition interaction for state procrastination, with both SSIs yielding significantly greater reductions than the control group and no significant difference between CBT and ACT. Similar patterns emerged for task-related anxiety and doubt, depressive symptoms, psychological flexibility (small-to-moderate gains), and perceived improvement. Higher baseline improvement expectations were associated with greater improvement, whereas expectation congruence and experimentally induced expectation violation did not differentially affect expectations or outcomes. Findings suggest that CBT- and ACT-based SSIs are effective, low-threshold options for reducing procrastination in students in the short term and highlight adherence and treatment expectations as important levers for optimizing brief interventions.

The efficacy of exposure-based cognitive behavioral therapy (eCBT) for panic disorder and agoraphobia (PD/AG) is well established, but the mechanisms of action are still under debate. Here we investigated whether increased fear activation (by provoking additional bodily symptoms using interoceptive challenges) during exposure to agoraphobic situations would improve therapy outcome. Individuals diagnosed with PD/AG (N=124) were randomized to one of the two variants of eCBT, with (exposure plus fear activation; E+FA) and without (exposure alone; E) guided evocation of unpleasant body symptoms (using additional interoceptive exposure exercises) and/or threat cognitions (expectations of potential threats that might occur during exposure). Primary outcome measures were assessed at baseline, post treatment, and at four-month follow-up. Reported fear and perceived likelihood of expected threat were assessed as moderators prior to, during, and after exposure sessions using ecological momentary assessment. Post treatment, E+FA was inferior to E in two of four primary outcome measures. At the follow-up assessment, both treatment variants were equally effective in all outcomes. In conclusion, increasing fear activation by explicitly activating the response units of the fear network did not result in better treatment outcome, questioning popular recommendations to maximize patient fear during eCBT - at least for patients with PD/AG.

Abstract Background Expectations are considered an important mechanism of change in psychotherapeutic interventions, including internet- and mobile-based interventions (IMI). This study aims to investigate whether two expectation-focused microinterventions can enhance the effects of an IMI for participants with elevated depression. Methods All participants will receive an established IMI consisting of six evidence-based cognitive behavioral modules. In this 2×3 factorial design, 720 adult participants will be randomized to receive (1) either the IMI in standard or personalized framing (first randomization factor), in combination with (2) an expectation-focused telephone call mid-treatment, a supportive phone call or no phone call (second randomization factor). The primary outcome is depression at mid- and post-treatment (BDI-II). Secondary measures include expectations, adherence, state and trait anxiety and depression, disability, negative effects, and satisfaction with treatment. Discussion This study will increase knowledge about applying micro-interventions to modify expectations and improve the effects of IMI in the treatment of depressive symptoms. Scalable IMI has the potential to improve healthcare but ways to further improve their effects and adherence need to be explored. Trial registration The trial was prospectively registered under DRKS00032982. Registered on July 11, 2023.

INTRODUCTION:Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative treatment for many hematologic malignancies, yet patient outcomes vary significantly. Patient expectations influence recovery in other medical contexts, yet their role in allo-HSCT remains unclear. This pilot study examined whether pre-transplant treatment expectations predict psychological and immunological outcomes post-transplant. METHODS:In this prospective, single-center observational cohort study, 42 patients undergoing allo-HSCT were assessed at baseline (T0), discharge (T2), and six months post-transplant (T3). Questionnaires measured illness-related disability (PDI, primary endpoint at T3), treatment expectations (TEX-Q), quality of life (FACT-Leu), depression (PHQ-9), and anxiety (GAD-7). Immunological markers, including inflammatory markers were collected at T0 and T3. Baseline-adjusted regression analyses with full-information maximum likelihood estimation were used. P-values were corrected for multiple comparisons using a false discovery rate approach. RESULTS:Baseline expectations were associated with psychological outcomes at hospital discharge and immunological and inflammatory markers at six-month follow-up: For instance, negative impact expectations were associated with higher disability (β = 0.522, p < 0.001), depression (β = 0.693, p = 0.009), anxiety (β = 0.737, p = 0.003), and lower quality of life (β = -0.576, p < 0.001) at T2. Benefit expectations were associated with higher lymphocyte counts (β = 0.453, p < 0.001) and lower CRP levels at T3 (β = -0.28, p = 0.011). Positive impact expectations were associated with more favorable T-cell subsets. DISCUSSION:Pre-transplant expectations may influence psychological and immune recovery following allo-HSCT. Addressing expectations could enhance outcomes and should be explored in future intervention studies.

INTRODUCTION:Treatment expectations for medical and psychological treatments and positive patient-provider interactions are critical mechanisms driving the placebo effect and may augment an intervention's effects. However, it remains unclear whether optimizing treatment expectations is beneficial for all individuals. This pilot randomized controlled trial (three-arm parallel design) examined whether i) optimizing treatment expectations would augment the efficacy of a mindfulness intervention and ii) whether participants' treatment expectations at baseline would moderate these effects. METHODS:Sixty-six healthy participants were randomized (1:1:1) to one of 3 experimental groups: i) body scan and an instruction aiming to optimize treatment expectations (EXPECT), ii) body scan and a neutral instruction (NEUTRAL), or iii) listening to an audiobook and neutral instruction (CONTROL). Primary outcomes were changes in positive and negative affect; secondary outcomes included treatment expectations, perceived stress, and mindfulness. Baseline expectations were assessed as a moderator using ANCOVA. RESULTS:ANCOVA indicated a group effect on positive affect (p = 0.018, d = 0.65), with individuals in the EXPECT group showing a stronger reduction than both other groups. Post-hoc comparisons showed significant differences between EXPECT and NEUTRAL (p = 0.015, d = -0.77) and between EXPECT and CONTROL (p = 0.012, d = -0.80). Analyzes did not indicate main effects on other outcomes. Participants with low baseline expectations showed a stronger increase in reported treatment expectations and mindfulness, as well as a more pronounced decrease in perceived stress from baseline- to post-assessment in the EXPECT group compared to both other groups. In contrast, individuals with high baseline expectations indicated less stress reduction when undergoing the body scan and receiving the instruction with positive expectation induction (EXPECT) compared to the group with a body scan and neutral instruction (NEUTRAL). CONCLUSION:Inducing positive treatment expectations may be beneficial for individuals with low baseline expectations, likely due to an enhanced placebo response. However, it may be counterproductive for individuals with high baseline outcome expectations and could reflect expectation violation effects.

Background The definition of psychological treatments and psychotherapy has various implications for communication within research and clinical care, as well as for legal issues — particularly in countries with psychotherapy acts. It can define what should be covered by public healthcare systems and who should be permitted to provide these services. Method We assembled a group of psychotherapists in Germany to develop an inclusive, scientific definition of psychotherapy. This definition should serve as an umbrella that is not limited to traditional treatment schools and is suitable for science, clinical care and legal acts. The group comprised people with different therapeutic backgrounds (e.g., CBT, psychodynamic and systemic therapy), experts from various disciplines (e.g., psychology, psychiatry and psychosomatic medicine), people focusing on different age groups (e.g., adults and youth), individuals with lived experience of psychotherapy and early career clinicians. Results A literature review led us to consider four aspects of a definition. What are the treatment means or 'tools'? (modality of treatment); how does the treatment work? (Proposed change mechanisms, assumptions about causal and evidence-based processes and concepts); who receives psychotherapy? (target group); and who provides psychotherapy? (Provider). Based on these aspects, we offer a definition of psychological therapy. Discussion Our suggested definition is not bound to specific treatment orientations, but is intended to encompass both traditional approaches and innovative developments. Our aim is to promote the evidence-based provision of psychological therapy within healthcare systems and legal frameworks.

Introduction:Treatment expectations play an important role in psychotherapy initiation and early treatment engagement may influence whether individuals decide to seek help. Negative expectations, concerns about burden, and anticipated risks may be particularly relevant for individuals with social anxiety. However, little is known about how different ways of framing treatment expectations influence help-seeking intentions. This study examined whether brief, role-model-based video interventions can modify treatment expectations and increase the subjective likelihood of seeking psychotherapy. Materials and methods:Participants (N = 123) were randomly assigned to one of three conditions: (1) avoidance-oriented framing, emphasizing the reduction of negative treatment expectations; (2) approach-oriented framing, highlighting potential positive treatment outcomes or (3) a minimal-intervention control condition. Treatment expectations (TEX-Q) and self-reported likelihood of seeking psychotherapy were assessed before and after the intervention. Results:Both video conditions increased subjective treatment-seeking probability compared to the control group, with a stronger increase observed for avoidance-oriented framing. This pattern was replicated in a subsample with higher self-reported social anxiety. Effects on treatment expectations were less consistent. Conclusion:These findings suggest that expectation-focused communication may help address expectation-related barriers before psychotherapy begins. Avoidance-oriented framing may be particularly relevant in the early phase of treatment engagement, especially for individuals with higher self-reported social anxiety. Trial registration:The trial was registered at ClinicalTrials.gov: NCT06022432.

Background Improving treatment outcomes for unipolar depression and anxiety disorders remains a major challenge in mental health care, particularly for patients who do not respond sufficiently to established interventions. Personalized approaches that target individual processes of change may enhance effectiveness. Process-based therapy aims to tailor interventions based on empirically supported psychological processes using idiographic data. Network control theory provides a complementary framework to identify interventions that can optimally influence complex dynamic systems. The present study introduces a control-theory-informed process-based therapy and evaluates its efficacy compared to routine cognitive behavioral therapy in patients with difficult-to-treat depression and anxiety disorders. Methods In this randomized controlled trial, 80 outpatients with a primary diagnosis of a depressive or anxiety disorder and at least two prior unsuccessful treatments will be recruited. Participants will be randomly assigned to either control-theory-informed process-based therapy or routine cognitive behavioral therapy. Both conditions include a 5-week baseline phase followed by a 19-week treatment phase. In the experimental condition, ecological momentary assessment data will be used to construct individualized dynamic networks of psychological functioning. These networks inform treatment decisions using control-theoretic metrics, including average controllability and cumulative impulse response, to identify interventions expected to produce maximal system-wide change. The primary outcome is emotional distress at post-treatment and 6-month follow-up. Secondary outcomes include quality of life, psychological well-being, and process variables such as psychological flexibility and reflective functioning. Analyses will follow an intention-to-treat approach using repeated-measures repeated-measures ANOVAs for primary outcome and repeated-measures MANOVA for secondary outcomes. Discussion This trial is the first to combine process-based therapy with network control theory in a randomized controlled design. By integrating individualized assessment with formal decision-support tools, the proposed approach seeks to improve treatment outcomes in a clinically challenging population. The study may advance precision mental health by providing empirical evidence for a novel, data-driven framework of personalized psychotherapy. In addition, the investigation of mediators and moderators may improve understanding of mechanisms of change and help inform future treatment optimization. Trial registration Clinical Trial Registry: DRKS00037966, Date of registration in DRKS: 2025-11-21 (See for more details: German Clinical Trials Register, https://drks.de/search/en/trial/DRKS00037966/details )

Patients' expectations about treatment benefits are robust predictors of clinical outcomes across medical and psychological contexts. Recent evidence suggests that expectancy effects in digital mental health interventions (DMHIs) are comparable in magnitude to those observed in face-to-face treatments. Despite their relevance, systematic guidance on how expectations can be shaped and optimized within DMHIs is limited. This narrative review summarizes theoretical and empirical work on expectations, including placebo and nocebo mechanisms, and digital intervention design to outline how expectation principles may be integrated into DMHIs. We describe three overarching principles - proactive expectation management, warmth and competence, and observational learning - and discuss how these mechanisms can be translated into practice across different stages and components of DMHI, including recruitment and onboarding, content, guidance, and interface design. We further highlight opportunities for expectation monitoring, automated feedback, and just-in-time adaptive interventions to support expectations. While modifications to single components may yield limited effects, coordinated, expectation-informed optimization across multiple DMHI components may have the potential to meaningfully enhance engagement and clinical outcomes. We conclude by discussing conceptual and methodological considerations and outline promising future directions for integrating the expectation lens within digital mental health.

Psychological interventions for delusions may be enhanced by targeting their presumed causal factors. An emotion-oriented variant of cognitive behavioral therapy for delusions (CBTd-E), designed to target affect regulation and maladaptive schemata, was evaluated for its effect on delusions. A single-blind, multicenter, randomized, waitlist-controlled trial was conducted in three German outpatient clinics. Ninety-four patients with psychotic disorders and persistent delusions were randomized to 25 individual sessions of CBTd-E over 6 months (n = 47) or waitlist (n = 47). CBTd-E included two modules designed to improve affect regulation and maladaptive schemata. Assessments were performed at baseline (T1), three months (T2), and six months (T3). Regression-based analysis of covariance at T3 in the intent-to-treat sample indicated no significant benefit for the CBT-E group in the primary outcome (Psychotic Symptom Rating Scale delusions subscale, d = -0.45 [CI: 0.36; -1.26]). Regarding secondary outcomes, a significant effect favoring CBTd-E was observed in general psychopathology (d = -0.56), but no effects on positive and negative symptoms, depression, general and social functioning, or antipsychotic dosage. Regarding the proposed target mechanisms, we found improved cognitive reappraisal (d = 0.59), worrying (d = -0.52), quality of sleep (d = -0.49), and self-esteem (d = 0.36). Despite its effect on the suggested target mechanisms, affect regulation and maladaptive schemata, and on general psychopathology, this emotion-focused variant of CBT did not show an effect on delusions. A possible avenue to achieve stronger effects on delusions is to personalize the modularized interventions. Trial registration: Clinicaltrials.gov Identifier: NCT02787135

Loneliness is a major obstacle for bereaved individuals. Negative expectations concerning social interactions contribute to loneliness and impede grief recovery. Disconfirming social experiences can violate these expectations. This study examines the efficacy of an expectation violation intervention in reducing grief-related negative social expectations and loneliness. This randomized controlled online trial with 129 bereaved participants (30.21 ± 11.17 years; 86.6

Background Affective and psychotic disorders share overlapping symptom constellations, environmental and genetic risk factors, and neurocognitive profiles. However, the nature of this association is not well understood, and accumulating evidence suggests a dimensional rather than categorical distinction between healthy and clinical populations. Objective This study investigated the relationships linking childhood trauma, positive and negative symptoms, depression symptoms, anxiety symptoms, and neurocognitive functioning such as verbal intelligence, executive functioning, and semantic processing within a unified transdiagnostic network. Methods We employed a partial correlation network and directed acyclic graph (DAG) analysis in a large psychiatric sample of 2444 participants, including 1364 patients with affective disorders or psychotic disorders, and 1080 healthy controls. Using self-report scales, clinician ratings, and neurocognitive tests, we analyzed risk and symptom clusters and developed a preliminary predictive model of these associations. Results Distinct, interconnected clusters of psychopathological symptoms emerged in the Gaussian Graphical Model (GGM), with strong connections between depression and anxiety clusters. Neurocognition and childhood trauma showed sparser associations with psychopathological symptoms. Nodes from self- and observer-ratings formed surprisingly strong bridges, especially concerning libido problems, lack of hobbies, social anhedonia, and loss of interest. DAG analyses indicated symptoms of low mood, reduced wellbeing, not feeling safe, and having difficulties initiating work or activities in general as potential predictors of downstream symptoms. Conclusion Complex associations between psychopathological and neurocognitive functioning emerged, with (the lack of) self-reported happiness, and well-being as key nodes. Future research should validate the clinical utility by using longitudinal network analyses and experimental data.

The COVID-19 pandemic necessitated rapid transitions to digital psychotherapy delivery formats, yet systematic quantification of these developments within psychotherapy research remains limited. This study presents an updated trend analysis of psychotherapy randomized controlled trials (RCTs) from 2019 to 2023. Systematic searches in PubMed, Web of Science and PsycINFO identified RCTs across predefined psychotherapeutic intervention categories. Trials were categorized by treatment approach, region and age group. A total of 1223 psychotherapy RCTs were identified. Despite a temporary decline in 2022 (-13%), the overall number of trials increased by 26.3% across the study period. eHealth interventions constituted the largest psychotherapeutic intervention category (43%), surpassing cognitive behavioural therapy (CBT; 37%). Among eHealth trials, 71% evaluated internet-delivered CBT. Only eHealth and telehealth showed statistically significant increases in proportional representation over time. Other therapeutic approaches each represented < 7% of treatment arms and showed no significant proportional change. Trial activity remained concentrated in high-income countries (73.4%) and predominantly targeted adult populations, with children and adolescents comprising 17.3% of trials. The findings illustrate a dynamic field that remained active during the COVID-19 crisis, with eHealth emerging as the most frequently investigated therapeutic approach accompanied by substantial growth in telehealth interventions. Despite the overall growth in trial activity, research efforts remained heavily concentrated around CBT-derived interventions, adult populations and high-income country settings.

ObjectiveAn effective tool for establishing concordant end-of-life (EOL) care in patients with cancer is advance care planning (ACP). However, various barriers, including psychological obstacles, hamper the access to ACP. Therefore, a new conceptual model combining a psycho-oncological approach with structured ACP was developed. The effectiveness and efficiency of this new concept of collaborative ACP (col-ACP) is evaluated in the present randomised controlled trial in patients with palliative cancer.Methods277 patients with palliative cancer and their relatives were randomised into three groups (1) collaborative ACP (col-ACP) consisting of a psycho-oncological approach addressing barriers to EOL conversations followed by a standardised ACP procedure, (2) supportive intervention (active control) and (3) standard medical care.ResultsPatients in the col-ACP group completed advance directives (p<0.01) and healthcare proxies (p<0.01) significantly more often. Additionally, they felt better planned ahead for their future treatment (p<0.01) and were significantly more confident that their relatives were aware of their treatment wishes (p=0.03). In fact, their goals of care were known and highly fulfilled. However, patients’ and caregivers’ quality of life, patients’ stress, depression and peace did not differ between the groups.ConclusionsThe new, well-received, concept of col-ACP improves readiness and access to ACP and results in more consistent EOL care. Further, even if no direct influence on quality of life could be proven, it supports patients in planning their treatment, making autonomous decisions and regaining self-efficacy in the face of life-limiting cancer. Therefore, a closer interlocking and information exchange between psycho-oncological and ACP services seems to be reasonable.Trial registration numberNCT03387436.

Background: Expectations regarding social interactions shape how individuals experience and express grief following the loss of a significant person. When these expectations are negative or dysfunctional, they can impede coping and contribute to prolonged distress. Expectation-violating experiences (i.e., positive social interactions) may promote psychological recovery, but their role in bereavement remains underexplored. Objective: This study qualitatively examined written accounts of grief-related expectation violations in social interactions, exploring how situational factors influence these experiences and identifying parameters relevant for grief-specific psychotherapy. Method: We conducted mixed methods analyses using data from an online controlled trial of an imagery-based expectation violation intervention. Qualitative data were collected from 47 bereaved participants (Mage = 30.69 years, SD=11.32; range=18-55; 87.2 % female) who described situations where their grief-related social expectations were disconfirmed. Responses were analyzed using reflexive thematic analysis and linked to quantitative demographic and symptom measures. Results: Two themes of negative social expectations emerged: expectations about others' behavior and expectations about one's own experience. Expectation violations also comprised two themes: behaviors of others and their impact on the bereaved. Most participants described both aspects of expectation violation, which was linked to a greater reduction in negative social expectations. Qualitative themes were not significantly associated with demographic or loss-related variables. Conclusions: Interactions that are validating and reciprocal may foster connectedness and support recovery after loss. The findings underscore the importance of interpersonal interactions and self-awareness for changing expectations. Behavioral experiments should consider how the disconfirming behavior of others impacts the bereaved person's self-perception.

Safety behavior is used to prevent or minimize perceived threats and contributes to the maintenance of anxiety disorders. Various types of safety behavior (e.g. cognitive, interoceptive strategies, aids, substances) are prevalent. Although assumed to be counterproductive during exposure-based CBT, little is known about its frequency and course across exposure exercises and its relation to treatment outcome. This study examined safety behavior during exposure-based CBT in a large multicenter outpatient sample and investigated its association with treatment outcome and clinical and exposure characteristic correlates. Safety behavior was dichotomously assessed after each exposure exercise using standardized worksheets (7,301) from 639 patients with panic disorder/agoraphobia, social anxiety disorder, or multiple specific phobia. Despite instructions to refrain from it, approximately half of patients reported safety behavior during their first exposure, most frequently cognitive strategies. It decreased significantly across exercises. More frequent safety behavior was associated with less symptom improvement and occurred more often with higher anticipatory and actual fear. Decline was steeper in therapist-guided than self-directed exposures, although therapist-guided exposures occurred first. Safety behavior is common early in exposure-based CBT and decreases across exposure exercises. Continuous monitoring appears important given its associations with clinical variables, exposure characteristics, and treatment outcome.Trial registration: NIMH Protocol Registration System (01EE1402A), German Register of Clinical Studies (DRKS00008743).

In psychological therapy, clinical training and practice is usually based on one or several of the traditional theoretical treatment orientations' subvariants and varies considerably from country to country. However, no traditional clinical theory provides a fully defined and tested causal network between concepts of disorders and clinical interventions that includes tests of alternative explanations. Adhering to the traditional orientations also bears the risk of hindering innovation and the dynamic exchange of ideas. As a consequence, therapists decide which theory to follow based on their country's specific regulations and their personal taste. In this position paper, we recommend that the field moves toward evidence- and practice-based, personalized treatment planning and interventions that focus on patients' specific problem patterns and actual treatment progress, instead of prioritizing one theoretical framework. We present an open framework for evidence-based, transtheoretical, and transdiagnostic psychological therapy. This framework could stimulate progress in research as well as future developments in competence-based clinical training and practice.

BACKGROUND:Negative expectations towards the future are frequently observed in patients with major depressive disorder (MDD) and linked to less favourable outcomes like worse treatment response and suicidal behaviours. Despite clinical significance, the neurobiological underpinnings of negative expectations remain largely unexplored. METHODS:This study compared structural MRI morphometric gray matter volume (SPM/CAT12) and two-year longitudinal clinical data between two groups of patients with DSM-IV-TR MDD (total N = 330), matched for age, sex, severity of depressive symptoms (HAMD), and global functioning (GAF scale), but differing in presence or absence of negative expectations assessed with the BDI-I item 2 "pessimism". RESULTS:In patients with negative expectations, the gray matter volume of the right middle frontal gyrus (rMFG) was increased compared to patients without negative expectations. Patients who expressed negative expectations at baseline had significantly longer duration of depressive episodes during the two-year follow-up period. Average duration of subclinical depressive episodes during follow-up was significantly predicted by the rMFG volume. CONCLUSION:This study showed a correlation between negative expectations and brain structure, as well as with the course of illness. Clinically it sets the stage for future research into therapeutic interventions targeting patients' expectations as a potential modulator towards a more favourable outcome in MDD patients with negative expectations.