Don’t worry – a question of interpretation?

So far, the results regarding the efficacy of CBM when delivered online are very mixed, although this has always been seen as an apparent advantage of CBM. Hirsch and colleagues present an RCT of an internet-delivered interpretation training to reduce worrying in patients with GAD. Participants listened to scenarios describing situations that related to common worry-related themes. They were asked to generate vivid mental images of a positive resolution for each scenario. Spoiler alert: This positive interpretation training reduced worry, anxiety, and depression up to 3 months after training was finished. This shows that CBM can be effective in a clinical population, even when delivered online.


Hirsch, C. R., Krahé, C., Whyte, J., Krzyzanowski, H., Meeten, F., Norton, S., & Mathews, A. (2021). Internet-delivered interpretation training reduces worry and anxiety in individuals with generalized anxiety disorder: A randomized controlled experiment. Journal of consulting and clinical psychology, 89(7), 575.


Commentary by Simon Blackwell
Ruhr-Universität Bochum, Germany

This paper by Hirsch et al. (2021) presents the latest in a series of high-quality studies investigating a cognitive bias modification paradigm targeting interpretation biases (CBM-I) in the context of generalized anxiety and depression. Given the fact that the intervention (and in fact all study procedures) were delivered entirely remotely to a sample of people meeting diagnostic criteria (assessed via telephone interview) for generalized anxiety disorder, the encouraging findings indicate that this CBM-I approach is a particularly promising one with exciting clinical potential, particularly in the context of the similar positive results from the preceding studies in this line of research (Hirsch et al., 2018; Hirsch et al., 2020). However, beyond these promising ‘headline’ results, the study is notable from a number of additional perspectives, two of which I will highlight here.

First, the study represents a very interesting progression of development of the CBM-I intervention under investigation. One aspect of this development is the removal of any face-to-face contact prior initiation of the training, which greatly increases both the accessibility and scalability of this CBM-I as an intervention when viewed from a dissemination perspective. A second aspect of this development is how the training paradigm itself has also been improved in a way to increase its potential clinical impact: This study uses an ‘enhanced’ version of the CBM-I first tested in the preceding study (Hirsch et al., 2020), which was an improvement on the version tested in an earlier clinical study (Hirsch et al., 2018), which in itself included attempts to improve on the version tested in previous experimental lab-based studies (Hirsch et al., 2009; Hayes et al., 2010). In addition, the instructions to participants were modified to include a suggestion that if the participant found themselves worrying in daily life they could try to identify positive outcomes, as practised in the training. This is a departure from most standard CBM implementations, as traditionally participants have simply been asked to complete training sessions, with the hope that within-session learning will somehow generalize and transfer to daily life. However, this traditional approach is hard to reconcile with theories of learning, which would suggest that such generalization will be limited in the absence of deliberate practice applying learning outside of the training context. Hence, this small addition to the training instructions could potentially have a large impact on clinical outcomes.

The second aspect of the study I will highlight is its position in the clinical translation process. The CBM-I here was delivered very much in a research study context, for example in term of recruitment avenues, the rationale for the CBM-I presented (see the Supplementary Materials), and the control condition. If we wish to arrive at a point where we can recommend it as a treatment, we need to test it as such: in a treatment-seeking population, presented with an explicit treatment rationale. Further, we would want to know whether the CBM-I was superior or non-inferior to other potential treatment options (requiring similar cost and time investment) we might offer to someone seeking help in this context. From this perspective, the study is a particularly interesting example of a potential new treatment paradigm at the cusp of transformation into a clinical intervention; how exactly this transition is managed will definitely be an exciting area to watch.


Commentary by Nessa Ikani
Radboud Medical Centre, & ProPersona, The Netherlands

The study by Hirsch et al. (2021) offers a strong translational account of the potential efficacy of an online-delivered cognitive bias modification interpretation (CBM-I) training aimed at ameliorating anxiety and worry in individuals meeting diagnostic criteria for GAD, with or without comorbid depression. Building on previous studies that already yielded positive effects of a CBM-I and enhanced CBM-I training in lab and home-based settings (Hirsch et al., 2018; 2020), the current study particularly underscored the potential of CBM-I by showing similar positive and sustained effects when offering the training remotely without face-to-face contact at any point before, during or after the training. This line of research exemplifies a clear bench-to-bedside approach, yet also demonstrates the mechanistic role of interpretation bias in maintaining repetitive negative thinking, anxiety and depressive symptoms.

Importantly, this study also addressed effects of CBM-I in the context of comorbidity. While comorbidity is often more the rule than the exception in clinical practice, the majority of CBM studies tend to include homogeneous samples with specific disorders or only assess the primary disorder. The comparison of individuals meeting diagnostic criteria for GAD or comorbid GAD and depression revealed that effects did not vary by presence of comorbidity. These findings, as well as the observed decreases in rumination and depressive symptoms following a CBM-I training that was specifically tailored to worry-related scenarios, highlight its promising transdiagnostic impact.

Besides its (augmenting) effects with potential clinical and scalable contributions, the remote CBM-I training also paves the way for research on interactions between interpretation bias, context and symptoms in daily life. The study’s use of self-generated positive outcomes for half of the training scenarios, in addition to the use of provided positive resolutions, is commendable as it promotes engagement and generalizations to daily life. Combining this idiosyncratic CBM-I approach with ambulatory assessments of repetitive negative thinking, anxiety and mood, can shed further light on the training’s transfer effects to the within-person interplay between interpretation bias, context, mood changes and symptoms. In doing so, it can aid in testing the premise of cognitive models, stating that negatively appraised context and negative mood activate maladaptive schemas and associated negative interpretation bias – in everyday life rather than lab-based contexts.

Taken together, this empirical work by Hirsch et al. generates important translational advances of CBM-I for clinical practice. Moreover, it provides a better mechanistic understanding of the causal and transdiagnostic role of maladaptive interpretations in repetitive negative thinking, anxiety and depressive symptoms. Lastly, it fosters new avenues for CBM-I research on everyday dynamics and interactions in individual contexts, thereby bringing it closer to daily life.

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