{ "name": "The Gap Between: Gap Numbers", "description": "One Gap Number per page of The Gap Between: the peer-reviewed study each page rests on, its sample, its key finding, and its DOI. Every value is copied from the published page.", "publisher": "Ignite Synergy (maker of Asendar)", "url": "https://www.asendar.com/gap/facts.json", "license": "Cite with a link to the page URL.", "disclaimer": "Education only, not medical advice. Findings describe the cited studies, not any product.", "count": 70, "facts": [ { "id": "does-ketamine-help-treatment-resistant-depression", "question": "Does ketamine help treatment-resistant depression?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/does-ketamine-help-treatment-resistant-depression", "markdown": "https://www.asendar.com/gap/q/does-ketamine-help-treatment-resistant-depression.md", "published": "2026-10-27", "gapNumber": "73 adults with treatment-resistant depression in a two-site randomized controlled trial", "shortAnswer": "Early research says yes, with a catch. In people whose depression has not responded to other treatments, a single ketamine infusion can lift symptoms within a day, far faster than a usual antidepressant. But the relief often fades within a few weeks, so it works best as the start of a plan, not a one-time fix.", "keyFinding": "James Murrough and colleagues ran a randomized controlled trial of ketamine for treatment-resistant depression, meaning depression that had not improved after other treatments. They enrolled 73 adults across two sites and compared a single ketamine infusion against a single infusion of an active placebo, a sedative chosen because it feels similar going in, so that neither the patients nor the raters could easily tell the two apart. Depression was measured with a standard clinician-rated scale, the Montgomery-Asberg Depression Rating Scale, where a higher number means more severe depression. Twenty-four hours after the infusion, the ketamine group had fallen about 8 points further on that scale than the placebo group. Put another way, 64 percent of the ketamine group had responded at 24 hours, meaning their depression had at least halved, compared with 28 percent of the placebo group. The effect was rapid, arriving within a day rather than the weeks a typical antidepressant takes. The authors were careful about the limits. They measured a single infusion at one day out, and they wrote plainly that more information on how long the response lasts, and on safety, was needed before the treatment could be relied on in everyday care.", "study": { "authors": "Murrough, J. W., Iosifescu, D. V., Chang, L. C., Al Jurdi, R. K., Green, C. E., Perez, A. M., Iqbal, S., Pillemer, S., Foulkes, A., Shah, A., Charney, D. S., and Mathew, S. J.", "year": "2013", "title": "Antidepressant Efficacy of Ketamine in Treatment-Resistant Major Depression: A Two-Site Randomized Controlled Trial", "journal": "American Journal of Psychiatry", "citation": "American Journal of Psychiatry, volume 170, issue 10, pages 1134 to 1142", "doi": "10.1176/appi.ajp.2013.13030392", "url": "https://doi.org/10.1176/appi.ajp.2013.13030392" }, "sources": [ "Murrough, J. W., Iosifescu, D. V., Chang, L. C., Al Jurdi, R. K., Green, C. E., Perez, A. M., Iqbal, S., Pillemer, S., Foulkes, A., Shah, A., Charney, D. S., & Mathew, S. J. (2013). Antidepressant Efficacy of Ketamine in Treatment-Resistant Major Depression: A Two-Site Randomized Controlled Trial. American Journal of Psychiatry, 170(10), 1134-1142. https://doi.org/10.1176/appi.ajp.2013.13030392", "Murrough, J. W., Perez, A. M., Pillemer, S., Stern, J., Parides, M. K., aan het Rot, M., Collins, K. A., Mathew, S. J., Charney, D. S., & Iosifescu, D. V. (2013). Rapid and Longer-Term Antidepressant Effects of Repeated Ketamine Infusions in Treatment-Resistant Major Depression. Biological Psychiatry, 74(4), 250-256. https://doi.org/10.1016/j.biopsych.2012.06.022", "Daly, E. J., Trivedi, M. H., Janik, A., et al. (2019). Efficacy of Esketamine Nasal Spray Plus Oral Antidepressant Treatment for Relapse Prevention in Patients With Treatment-Resistant Depression. JAMA Psychiatry, 76(9), 893-903. https://doi.org/10.1001/jamapsychiatry.2019.1189" ] }, { "id": "does-psilocybin-therapy-help-with-depression", "question": "Does psilocybin therapy help with depression?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/does-psilocybin-therapy-help-with-depression", "markdown": "https://www.asendar.com/gap/q/does-psilocybin-therapy-help-with-depression.md", "published": "2026-10-26", "gapNumber": "24 adults with major depression who completed two supervised psilocybin sessions paired with supportive therapy", "shortAnswer": "Early research says yes, with real promise and real limits. Small trials of psilocybin-assisted therapy found large drops in depression, lasting up to a year for some people. A larger, more rigorous trial found a smaller benefit that was less clearly lasting. It is still investigational, studied only in supervised settings.", "keyFinding": "Alan Davis and colleagues at Johns Hopkins ran a small randomized trial of psilocybin-assisted therapy for major depression. They enrolled 27 adults and compared starting treatment right away with waiting about eight weeks first. Twenty-four people completed the program, which paired two supervised psilocybin sessions with around eleven hours of talking therapy before, between, and after. Depression was measured with a standard clinician-rated scale, the GRID-Hamilton Depression Rating Scale, where a higher score means more severe depression. The group that started right away improved far more than the group still waiting. Their average score fell from the severe range, about 23, down to around 8 at both one week and four weeks after treatment, while the waiting group stayed high. By the usual statistical measure the gap between the groups was very large. At four weeks, 71 percent of people had responded, meaning their depression had at least halved, and 54 percent were in remission, meaning their symptoms had mostly cleared. The authors were careful about what this shows. It was a small, early trial run in a supervised research setting, not evidence that the treatment works for everyone or outside that kind of setting.", "study": { "authors": "Davis, A. K., Barrett, F. S., May, D. G., Cosimano, M. P., Sepeda, N. D., Johnson, M. W., Finan, P. H., and Griffiths, R. R.", "year": "2021", "title": "Effects of Psilocybin-Assisted Therapy on Major Depressive Disorder: A Randomized Clinical Trial", "journal": "JAMA Psychiatry", "citation": "JAMA Psychiatry, volume 78, issue 5, pages 481 to 489", "doi": "10.1001/jamapsychiatry.2020.3285", "url": "https://doi.org/10.1001/jamapsychiatry.2020.3285" }, "sources": [ "Davis, A. K., Barrett, F. S., May, D. G., Cosimano, M. P., Sepeda, N. D., Johnson, M. W., Finan, P. H., & Griffiths, R. R. (2021). Effects of Psilocybin-Assisted Therapy on Major Depressive Disorder: A Randomized Clinical Trial. JAMA Psychiatry, 78(5), 481-489. https://doi.org/10.1001/jamapsychiatry.2020.3285", "Gukasyan, N., Davis, A. K., Barrett, F. S., Cosimano, M. P., Sepeda, N. D., Johnson, M. W., & Griffiths, R. R. (2022). Efficacy and safety of psilocybin-assisted treatment for major depressive disorder: Prospective 12-month follow-up. Journal of Psychopharmacology, 36(2), 151-158. https://doi.org/10.1177/02698811211073759", "Goodwin, G. M., Aaronson, S. T., Alvarez, O., et al. (2022). Single-Dose Psilocybin for a Treatment-Resistant Episode of Major Depression. New England Journal of Medicine, 387(18), 1637-1648. https://doi.org/10.1056/nejmoa2206443" ] }, { "id": "do-mental-health-apps-help-between-therapy-sessions", "question": "Do mental health apps help between therapy sessions?", "pillar": "integration", "page": "https://www.asendar.com/gap/q/do-mental-health-apps-help-between-therapy-sessions", "markdown": "https://www.asendar.com/gap/q/do-mental-health-apps-help-between-therapy-sessions.md", "published": "2026-10-25", "gapNumber": "66 randomized controlled trials of app-supported smartphone interventions", "shortAnswer": "Often, a little. A 2019 meta-analysis of 66 trials found mental health apps beat no app for depression, anxiety, and stress, with small effects. They helped most when a real person was involved and reminders kept people coming back. Useful support between sessions, not a replacement for care.", "keyFinding": "Jake Linardon and colleagues pooled 66 randomized controlled trials of smartphone apps for mental health, the largest such review at the time. Across the trials, apps did better than the control conditions for several common problems: a small effect on depression (Hedges' g of 0.28), on generalized anxiety (0.30), on stress (0.35), and on quality of life (0.35). A larger g means a stronger effect, and these numbers sit at the small end, which means a real but modest average benefit rather than a dramatic one. The apps did not beat the controls for panic symptoms, post-traumatic stress symptoms, or negative mood. Two things made the apps work better: building them on cognitive behavioral therapy, and pairing them with some human guidance and reminders that nudged people to keep using them. The authors were careful to say these tools are meant to support care, not to stand in for a clinician.", "study": { "authors": "Linardon, J., Cuijpers, P., Carlbring, P., Messer, M., and Fuller-Tyszkiewicz, M.", "year": "2019", "title": "The efficacy of app-supported smartphone interventions for mental health problems: a meta-analysis of randomized controlled trials", "journal": "World Psychiatry", "citation": "World Psychiatry, volume 18, issue 3, pages 325 to 336", "doi": "10.1002/wps.20673", "url": "https://doi.org/10.1002/wps.20673" }, "sources": [ "Linardon, J., Cuijpers, P., Carlbring, P., Messer, M., & Fuller-Tyszkiewicz, M. (2019). The efficacy of app-supported smartphone interventions for mental health problems: a meta-analysis of randomized controlled trials. World Psychiatry, 18(3), 325-336. https://doi.org/10.1002/wps.20673", "Firth, J., Torous, J., Nicholas, J., Carney, R., Pratap, A., Rosenbaum, S., & Sarris, J. (2017). The efficacy of smartphone-based mental health interventions for depressive symptoms: a meta-analysis of randomized controlled trials. World Psychiatry, 16(3), 287-298. https://doi.org/10.1002/wps.20472" ] }, { "id": "how-can-a-clinic-tell-if-treatment-is-working", "question": "How can a clinic tell if treatment is working?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/how-can-a-clinic-tell-if-treatment-is-working", "markdown": "https://www.asendar.com/gap/q/how-can-a-clinic-tell-if-treatment-is-working.md", "published": "2026-10-24", "gapNumber": "A review of 51 articles on measurement-based care, not a single trial of patients. It gathers the evidence on what kind of symptom tracking changes outcomes and what kind does not, drawing on published studies and a focus group of experts.", "shortAnswer": "By measuring, the right way. A 2017 review in Psychiatric Services found that clinics can tell whether treatment is working when they collect a brief validated symptom score often, on time, and review it with the patient during the visit. One-time screening and scores that arrive late do not help.", "keyFinding": "John Fortney and colleagues reviewed measurement-based care, which they define as giving a patient a validated symptom rating scale on a routine schedule and using the result to guide the next treatment decision. They pulled together 51 articles. The central finding was consistent: nearly every randomized trial that fed frequent, timely patient-reported scores back to the clinician during the encounter improved outcomes. Just as important was what did not work. One-time screening, assessment done only now and then, and feedback that reached the provider outside the visit did not improve results. In short, measurement helps a clinic see whether treatment is working only when it is repeated, current, and in the room when decisions are made. The authors also reported that large pragmatic trials and demonstration projects suggest the approach can scale and is well accepted by both patients and providers, and that scores gathered across a caseload can support clinician development, quality improvement, and reporting to payers. They urged clinics to build measurement-based systems on their own terms before accreditation and payment changes required it. Because this is a narrative review rather than a pooled meta-analysis, it counts and weighs the studies rather than combining them into a single effect size.", "study": { "authors": "Fortney, J. C., Unützer, J., Wrenn, G., et al.", "year": "2017", "title": "A Tipping Point for Measurement-Based Care", "journal": "Psychiatric Services", "citation": "Psychiatric Services, volume 68, pages 179 to 188", "doi": "10.1176/appi.ps.201500439", "url": "https://doi.org/10.1176/appi.ps.201500439" }, "sources": [ "Fortney, J. C., Unützer, J., Wrenn, G., Pyne, J. M., Smith, G. R., Schoenbaum, M., & Harbin, H. T. (2017). A Tipping Point for Measurement-Based Care. Psychiatric Services, 68(2), 179-188. https://doi.org/10.1176/appi.ps.201500439" ] }, { "id": "why-do-patients-miss-mental-health-appointments", "question": "Why do patients miss mental health appointments?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/why-do-patients-miss-mental-health-appointments", "markdown": "https://www.asendar.com/gap/q/why-do-patients-miss-mental-health-appointments.md", "published": "2026-10-23", "gapNumber": "A systematic review and meta-analysis of 35 studies reporting on 40 datasets from general (nonspecialist) outpatient mental health clinics, searched through July 2024. Pooled estimates drew on 2,668 patients for first visits, 4,377 for second visits, and 3,634 for later visits.", "shortAnswer": "Missed visits are common, and they grow over time. A 2026 review of 35 studies found that about a third of patients missed their first outpatient mental health appointment, and the share kept climbing at later visits. Forgetting, money, distance, illness severity, and a weak bond with the clinician were all linked to missed visits.", "keyFinding": "Pavan Kuppili and colleagues searched three major research databases and pooled every study they could find on missed appointments in general outpatient mental health clinics. They report this was the first meta-analysis to pool these rates. About 34% of patients missed their first appointment. About 42% missed the second. At later appointments, the pooled rate was 64%. The studies varied a lot from one another, so these are averages across very different clinics, not a fixed number for any one practice. Across the studies, the same factors kept showing up next to missed visits: very young or older age, low day to day functioning, forgetfulness, money trouble, more severe illness, personality or substance use disorders, a weak working bond with the clinician, negative views about the illness or the treatment, and living farther from the clinic. The authors concluded that missed appointments are common, that they rise with each visit, and that clinics need stronger engagement efforts.", "study": { "authors": "Kuppili, P. P., Singhai, K., Divyanish, D., Krishnamoorthy, Y., & Menon, V.", "year": "2026", "title": "Factors Associated With Nonattendance at Nonspecialist Outpatient Mental Health Clinics: Systematic Review and Meta-Analysis", "journal": "Psychiatric Services", "citation": "Psychiatric Services, volume 77, issue 8, pages 752 to 761", "doi": "10.1176/appi.ps.20250094", "url": "https://doi.org/10.1176/appi.ps.20250094" }, "sources": [ "Kuppili, P. P., Singhai, K., Divyanish, D., Krishnamoorthy, Y., & Menon, V. (2026). Factors Associated With Nonattendance at Nonspecialist Outpatient Mental Health Clinics: Systematic Review and Meta-Analysis. Psychiatric Services, 77(8), 752-761. https://doi.org/10.1176/appi.ps.20250094" ] }, { "id": "why-do-so-few-clinics-track-mental-health-outcomes", "question": "Why do so few clinics track mental health outcomes?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/why-do-so-few-clinics-track-mental-health-outcomes", "markdown": "https://www.asendar.com/gap/q/why-do-so-few-clinics-track-mental-health-outcomes.md", "published": "2026-10-22", "gapNumber": "A narrative review of the research on measurement-based care rather than a single study of patients. It gathers the evidence on how often the practice is used, what blocks it, and what helps a clinic adopt it.", "shortAnswer": "Not because clinics do not care. A 2019 JAMA Psychiatry review found that fewer than 20% of behavioral health practitioners regularly track outcomes with a validated measure. The reasons sit at every level: patient worries, practitioner doubt, thin time and budget, and competing rules. The barriers are known, and so are the fixes.", "keyFinding": "Cara Lewis and colleagues reviewed measurement-based care, the practice of giving a patient a brief validated symptom questionnaire before or during a visit and using the score to guide treatment. Despite strong evidence that it speeds improvement and catches patients who are quietly getting worse, they report that fewer than 20% of behavioral health practitioners use it regularly, and far fewer use it at every session. No earlier review had pulled together why, so this one set out to. The authors group the barriers into four levels. Patients can worry about how the information will be used. Practitioners may believe a short questionnaire adds little to their clinical judgment. Organizations often lack the time, training, and budget to support it. And the wider system adds competing paperwork and pays for visits rather than for tracking. The review then lists what helps: measurement feedback systems built into the workflow, respected local champions, learning collaboratives, leadership training, expert consultation for clinical staff, and incentives that line up with the practice. It closes with a 10-point research agenda, including better links to electronic health records and reimbursement that rewards tracking. Because it is a narrative review, it summarizes the evidence rather than pooling it into a single effect size.", "study": { "authors": "Lewis, C. C., Boyd, M., Puspitasari, A., et al.", "year": "2019", "title": "Implementing Measurement-Based Care in Behavioral Health: A Review", "journal": "JAMA Psychiatry", "citation": "JAMA Psychiatry, volume 76, issue 3, pages 324 to 335", "doi": "10.1001/jamapsychiatry.2018.3329", "url": "https://doi.org/10.1001/jamapsychiatry.2018.3329" }, "sources": [ "Lewis, C. C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., Hoffman, M., Scott, K., Lyon, A., Douglas, S., Simon, G., & Kroenke, K. (2019). Implementing Measurement-Based Care in Behavioral Health: A Review. JAMA Psychiatry, 76(3), 324-335. https://doi.org/10.1001/jamapsychiatry.2018.3329" ] }, { "id": "does-it-help-to-talk-through-mixed-feelings-before-therapy", "question": "Does it help to talk through mixed feelings before therapy?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/does-it-help-to-talk-through-mixed-feelings-before-therapy", "markdown": "https://www.asendar.com/gap/q/does-it-help-to-talk-through-mixed-feelings-before-therapy.md", "published": "2026-10-21", "gapNumber": "76 adults with a principal diagnosis of generalized anxiety disorder, recruited in the Toronto area and randomly assigned to two groups before both groups received individual CBT.", "shortAnswer": "It may help. In a 2009 trial of 76 adults with generalized anxiety, people who spent four sessions exploring their mixed feelings about change before starting CBT did more of their between-session practice and had more treatment responders. The gains were clearest when worry was severe, and the authors called the trial preliminary.", "keyFinding": "Henny Westra and colleagues randomly assigned 76 adults with generalized anxiety disorder to one of two starts. One group had four weekly 50-minute sessions of motivational interviewing (MI), a conversation style that explores mixed feelings about change. The other group waited four weeks with no pretreatment. Then everyone received cognitive behavioral therapy (CBT). On the main worry measure, 92% of the MI group (35 people) were treatment responders, against 71% (27 people) of the group with no pretreatment, and the MI group had no nonresponders, against 21% (8 people). CBT therapists rated the MI group as doing more of their homework, 4.59 against 4.19 on a 0 to 6 scale, a moderate effect (d of 0.59), and that homework difference helped explain the extra drop in worry. People's own ratings of their homework did not differ between groups. The benefit was concentrated in people with high worry at the start. That group showed some relapse at 6 months, and the advantage appeared again at 12 months. The authors described the results as preliminary, pending replication.", "study": { "authors": "Westra, H. A., Arkowitz, H., & Dozois, D. J. A.", "year": "2009", "title": "Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: A preliminary randomized controlled trial", "journal": "Journal of Anxiety Disorders", "citation": "Journal of Anxiety Disorders, volume 23, issue 8, pages 1106 to 1117", "doi": "10.1016/j.janxdis.2009.07.014", "url": "https://doi.org/10.1016/j.janxdis.2009.07.014" }, "sources": [ "Westra, H. A., Arkowitz, H., & Dozois, D. J. A. (2009). Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: A preliminary randomized controlled trial. Journal of Anxiety Disorders, 23(8), 1106-1117. https://doi.org/10.1016/j.janxdis.2009.07.014" ] }, { "id": "how-accurate-is-the-phq-9-for-measuring-depression", "question": "How accurate is the PHQ-9 for measuring depression?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/how-accurate-is-the-phq-9-for-measuring-depression", "markdown": "https://www.asendar.com/gap/q/how-accurate-is-the-phq-9-for-measuring-depression.md", "published": "2026-10-21", "gapNumber": "About 6,000 primary care and obstetrics-gynecology patients across 15 clinics completed the PHQ-9, and 580 of them also had a separate interview with a mental health professional that served as the yardstick.", "shortAnswer": "It is accurate enough to trust for a short questionnaire. In the study that validated it, a PHQ-9 score of 10 or higher flagged major depression correctly about 88% of the time, whether or not a person actually had it. Scores of 5, 10, 15, and 20 mark mild, moderate, moderately severe, and severe depression.", "keyFinding": "Kurt Kroenke, Robert Spitzer, and Janet Williams tested the PHQ-9, a nine-item questionnaire a person fills out about the symptoms of depression over the past two weeks. Each item is scored from 0 to 3, and the nine add up to a total from 0 to 27. About 6,000 patients across 15 primary care and women's health clinics completed it, and 580 of them also sat for a separate interview with a mental health professional, which served as the yardstick. Against that yardstick, a total score of 10 or more identified major depression with 88% sensitivity and 88% specificity. In plain terms, when the interview found depression the score caught it about 88% of the time, and when the interview found none the score agreed about 88% of the time. The authors set four thresholds, 5, 10, 15, and 20, to mark mild, moderate, moderately severe, and severe depression. As scores climbed, people reported worse daily functioning, more difficulty from their symptoms, and more sick days. The authors concluded the PHQ-9 is a reliable and valid measure of depression severity, brief enough for everyday care.", "study": { "authors": "Kroenke, K., Spitzer, R. L., & Williams, J. B. W.", "year": "2001", "title": "The PHQ-9: Validity of a Brief Depression Severity Measure", "journal": "Journal of General Internal Medicine", "citation": "Journal of General Internal Medicine, volume 16, issue 9, pages 606 to 613", "doi": "10.1046/j.1525-1497.2001.016009606.x", "url": "https://doi.org/10.1046/j.1525-1497.2001.016009606.x" }, "sources": [ "Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a Brief Depression Severity Measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x" ] }, { "id": "does-collaborative-care-work-across-different-clinics-and-conditions", "question": "Does collaborative care work across different clinics and conditions?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/does-collaborative-care-work-across-different-clinics-and-conditions", "markdown": "https://www.asendar.com/gap/q/does-collaborative-care-work-across-different-clinics-and-conditions.md", "published": "2026-10-20", "gapNumber": "57 randomized controlled trials, reported in 78 articles and yielding 161 analyses. 40 trials studied depression, 4 studied bipolar disorder, 3 studied anxiety disorders, and 10 covered multiple or other conditions, across primary care, specialty care, and behavioral health settings.", "shortAnswer": "Yes. A 2012 review of 57 randomized trials found collaborative care models improved mental health outcomes across primary care, specialty, and behavioral health settings, and across depression, anxiety, and bipolar disorder. The gains were small but consistent, and total health care costs did not rise.", "keyFinding": "Emily Woltmann and colleagues ran a systematic review and meta-analysis of collaborative chronic care models for mental health conditions. A program counted as a model if it used at least 3 of 6 chronic care components, such as self-management support, clinical information systems, redesigned care delivery, and decision support. They pooled 57 randomized trials (78 articles, 161 analyses): 40 on depression, 4 on bipolar disorder, 3 on anxiety disorders, and 10 on multiple or other conditions. The models improved depression, mental and physical quality of life, and social role function across disorders and across settings, with small effects (Cohen's d of 0.20 to 0.33). Total health care costs did not differ from comparison care. The authors concluded these models offer a robust framework for integrating care.", "study": { "authors": "Woltmann, E., Grogan-Kaylor, A., Perron, B., et al.", "year": "2012", "title": "Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings", "journal": "American Journal of Psychiatry", "citation": "American Journal of Psychiatry, volume 169, pages 790 to 804", "doi": "10.1176/appi.ajp.2012.11111616", "url": "https://doi.org/10.1176/appi.ajp.2012.11111616" }, "sources": [ "Woltmann, E., Grogan-Kaylor, A., Perron, B., Georges, H., Kilbourne, A. M., & Bauer, M. S. (2012). Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis. American Journal of Psychiatry, 169(8), 790-804. https://doi.org/10.1176/appi.ajp.2012.11111616" ] }, { "id": "does-keeping-family-in-the-loop-help-older-adults-after-a-hospital-or-rehab-stay", "question": "Does keeping family in the loop help older adults after a hospital or rehab stay?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/does-keeping-family-in-the-loop-help-older-adults-after-a-hospital-or-rehab-stay", "markdown": "https://www.asendar.com/gap/q/does-keeping-family-in-the-loop-help-older-adults-after-a-hospital-or-rehab-stay.md", "published": "2026-10-20", "gapNumber": "A systematic review and meta-analysis of randomized controlled trials. Of 10,715 abstracts screened, 15 trials met the criteria and 11 gave enough detail to pool readmission rates. Older adults with family or other informal caregivers, discharged from a hospital or skilled nursing facility to the community.", "shortAnswer": "Yes. A 2017 meta-analysis found that when family caregivers were built into discharge planning from a hospital or skilled nursing facility, older adults had 25 percent fewer readmissions at 90 days and 24 percent fewer at 180 days. Millions of families already coordinate care, often with little support.", "keyFinding": "Juleen Rodakowski and colleagues at the University of Pittsburgh pooled randomized trials that brought informal caregivers into discharge planning before an older adult left a hospital or skilled nursing facility. Compared with usual discharge, caregiver integration was associated with 25 percent fewer readmissions at 90 days (relative risk 0.75) and 24 percent fewer readmissions at 180 days (relative risk 0.76). Most of the trials also reported a longer time before readmission, shorter rehospital stays, and lower costs of care after discharge. A second study sets the scale. Jennifer Wolff and colleagues, writing in JAMA Internal Medicine in 2016, used national survey data from 2011 and estimated 14.7 million family and unpaid caregivers helping 7.7 million older adults with disabilities. Of those caregivers, 6.5 million, or 44.1 percent, gave substantial help with health care, meaning both coordinating care and managing medications. They gave 28.1 hours of help a week on average, yet only about one quarter used any supportive services.", "study": { "authors": "Rodakowski, J., Rocco, P. B., Ortiz, M., Folb, B., Schulz, R., Morton, S. C., Leathers, S. C., Hu, L., and James, A. E.", "year": "2017", "title": "Caregiver Integration During Discharge Planning for Older Adults to Reduce Resource Use: A Metaanalysis", "journal": "Journal of the American Geriatrics Society", "citation": "Journal of the American Geriatrics Society, volume 65, pages 1748 to 1755", "doi": "10.1111/jgs.14873", "url": "https://doi.org/10.1111/jgs.14873" }, "sources": [ "Rodakowski, J., Rocco, P. B., Ortiz, M., Folb, B., Schulz, R., Morton, S. C., Leathers, S. C., Hu, L., & James, A. E. (2017). Caregiver Integration During Discharge Planning for Older Adults to Reduce Resource Use: A Metaanalysis. Journal of the American Geriatrics Society, 65(8), 1748-1755. https://doi.org/10.1111/jgs.14873", "Wolff, J. L., Spillman, B. C., Freedman, V. A., & Kasper, J. D. (2016). A National Profile of Family and Unpaid Caregivers Who Assist Older Adults With Health Care Activities. JAMA Internal Medicine, 176(3), 372-379. https://doi.org/10.1001/jamainternmed.2015.7664" ] }, { "id": "does-online-cbt-work-better-with-human-support", "question": "Does online CBT work better with human support?", "pillar": "integration", "page": "https://www.asendar.com/gap/q/does-online-cbt-work-better-with-human-support", "markdown": "https://www.asendar.com/gap/q/does-online-cbt-work-better-with-human-support.md", "published": "2026-10-19", "gapNumber": "42 eligible randomized trials published up to January 2019. 39 of them shared patient-level data on 9,751 adults with depression, and data from 8,107 people were analyzed together, across 12 countries in Europe, North America, and China. An individual patient data network meta-analysis.", "shortAnswer": "Yes, on average, at least at first. A 2021 analysis of patient-level data from 39 trials and 9,751 people found online CBT for depression worked better when a coach or therapist checked in, mostly for moderate to severe depression. With mild symptoms the difference was small, and by six to twelve months it had faded.", "keyFinding": "Eirini Karyotaki and colleagues gathered the raw, person-by-person data from randomized trials of internet-based cognitive behavioral therapy (iCBT) for depression. They compared two kinds of program. Guided iCBT included therapeutic support from a professional or a trained paraprofessional, live or by message. Unguided iCBT allowed only automated or technical help. Both kinds did better than usual care and waiting lists on the PHQ-9 depression questionnaire, in the short term and over the longer term. Right after treatment, guided programs came out ahead of unguided ones by 0.8 points on the PHQ-9 (95% confidence interval 0.2 to 1.4 points). The edge depended on how depressed people were at the start. With mild or subthreshold symptoms (PHQ-9 of 5 to 9), guidance made little or no difference. With a PHQ-9 of 10 or more, which is moderate depression and above, guided programs did better, and the advantage grew with severity. At 6 and 12 months, the authors found no evidence of a difference between guided and unguided programs, though only 8 studies reported those follow-ups. Across the 25 studies that reported it, average adherence was 76% with guidance and 54% without.", "study": { "authors": "Karyotaki, E., Efthimiou, O., Miguel, C., Maas genannt Bermpohl, F., Furukawa, T. A., Cuijpers, P., and the Individual Patient Data Meta-Analyses for Depression (IPDMA-DE) Collaboration", "year": "2021", "title": "Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis", "journal": "JAMA Psychiatry", "citation": "JAMA Psychiatry, volume 78, issue 4, pages 361 to 371", "doi": "10.1001/jamapsychiatry.2020.4364", "url": "https://doi.org/10.1001/jamapsychiatry.2020.4364" }, "sources": [ "Karyotaki, E., Efthimiou, O., Miguel, C., Maas genannt Bermpohl, F., Furukawa, T. A., Cuijpers, P., Individual Patient Data Meta-Analyses for Depression (IPDMA-DE) Collaboration, et al. (2021). Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis. JAMA Psychiatry, 78(4), 361-371. https://doi.org/10.1001/jamapsychiatry.2020.4364" ] }, { "id": "what-makes-a-collaborative-care-program-actually-work", "question": "What makes a collaborative care program actually work?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/what-makes-a-collaborative-care-program-actually-work", "markdown": "https://www.asendar.com/gap/q/what-makes-a-collaborative-care-program-actually-work.md", "published": "2026-10-19", "gapNumber": "37 randomized controlled trials of collaborative care for depression in primary care, covering 12,355 patients. A cumulative meta-analysis that also reviewed longer-term outcomes and tested which program features tracked with larger effects.", "shortAnswer": "A 2006 review of 37 trials and 12,355 patients found collaborative care beat usual care for depression. What drove the effect was not more therapy sessions. It was patients staying with treatment, and case managers who had real professional training and regular supervision. The structure does the work.", "keyFinding": "Simon Gilbody and colleagues pooled 37 randomized studies of collaborative care for depression in primary care, covering 12,355 patients. Collaborative care meant structured care that gives non-medical specialists, such as case managers, a bigger role alongside the primary care clinician. Depression outcomes were better than standard care at 6 months (standardised mean difference 0.25), and a smaller, longer-term benefit held for up to 5 years (SMD 0.15, with a confidence interval that only just cleared zero). Effects were larger when patients stayed with their treatment, and they depended on the professional background and the supervision of the case managers. Adding brief psychotherapy, or more sessions, did not substantially improve outcomes. A cumulative analysis showed the evidence for collaborative care was already statistically clear by the year 2000.", "study": { "authors": "Gilbody, S., Bower, P., Fletcher, J., et al.", "year": "2006", "title": "Collaborative Care for Depression: A Cumulative Meta-analysis and Review of Longer-term Outcomes", "journal": "Archives of Internal Medicine", "citation": "Archives of Internal Medicine, volume 166, pages 2314 to 2321", "doi": "10.1001/archinte.166.21.2314", "url": "https://doi.org/10.1001/archinte.166.21.2314" }, "sources": [ "Gilbody, S., Bower, P., Fletcher, J., et al. (2006). Collaborative Care for Depression: A Cumulative Meta-analysis and Review of Longer-term Outcomes. Archives of Internal Medicine, 166(21), 2314-2321. https://doi.org/10.1001/archinte.166.21.2314" ] }, { "id": "does-collaborative-care-help-older-adults-with-depression", "question": "Does collaborative care help older adults with depression?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/does-collaborative-care-help-older-adults-with-depression", "markdown": "https://www.asendar.com/gap/q/does-collaborative-care-help-older-adults-with-depression.md", "published": "2026-10-18", "gapNumber": "1,801 primary care patients aged 60 or older with depression, across 18 clinics in 8 health care organizations in 5 US states. A randomized controlled trial comparing the IMPACT collaborative care program with usual care.", "shortAnswer": "Yes. In the IMPACT trial, 1,801 primary care patients aged 60 and older were randomized to collaborative care or usual care. At one year, 45 percent of the collaborative care group had cut their depression symptoms in half, against 19 percent in usual care. One large trial, run faithfully.", "keyFinding": "Jürgen Unützer and the IMPACT investigators ran a randomized controlled trial across 18 primary care clinics in 8 health care organizations in 5 US states. They enrolled 1,801 patients aged 60 or older with depression and split them at random into the IMPACT collaborative care program (906 patients) or usual care (895 patients). For up to 12 months, each IMPACT patient had a depression care manager, supervised by a psychiatrist and a primary care expert, who gave education, tracked progress, supported the primary care physician's treatment plan, and could offer a brief problem-solving therapy. At 12 months, 45 percent of the IMPACT patients had cut their depressive symptoms by half or more, compared with 19 percent in usual care, an odds ratio of 3.45. IMPACT patients were also more likely to receive depression treatment, more satisfied with their care, less impaired in daily function, and reported a higher quality of life. The authors concluded the model was workable and more effective than usual care across a wide range of practices.", "study": { "authors": "Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Hunkeler, E., Harpole, L., and the IMPACT Investigators", "year": "2002", "title": "Collaborative Care Management of Late-Life Depression in the Primary Care Setting", "journal": "JAMA", "citation": "JAMA, volume 288, pages 2836 to 2845", "doi": "10.1001/jama.288.22.2836", "url": "https://doi.org/10.1001/jama.288.22.2836" }, "sources": [ "Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H. B., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., & Langston, C. (2002). Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A Randomized Controlled Trial. JAMA, 288(22), 2836-2845. https://doi.org/10.1001/jama.288.22.2836" ] }, { "id": "does-collaborative-care-help-patients-with-depression-and-a-chronic-illness", "question": "Does collaborative care help patients with depression and a chronic illness?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/does-collaborative-care-help-patients-with-depression-and-a-chronic-illness", "markdown": "https://www.asendar.com/gap/q/does-collaborative-care-help-patients-with-depression-and-a-chronic-illness.md", "published": "2026-10-17", "gapNumber": "214 patients who had depression together with poorly controlled diabetes, coronary heart disease, or both, across 14 primary care clinics in an integrated health system in Washington State. A single-blind randomized controlled trial.", "shortAnswer": "Yes. In a randomized trial of 214 patients who had depression alongside diabetes or heart disease, a nurse-led team that worked on the mind and the body together improved depression and the physical markers more than usual care at one year. It was one small trial in one health system, so read it as promising, not settled.", "keyFinding": "Wayne Katon and colleagues ran the TEAMcare trial in 14 primary care clinics in Washington State. They enrolled 214 patients who had depression along with poorly controlled diabetes, coronary heart disease, or both, and split them at random into usual care or the intervention. In the intervention, a medically supervised nurse worked with each patient's primary care physician to manage all of the patient's conditions at once, following treatment guidelines and tracking progress toward clear targets. After 12 months, the intervention group improved more than usual care on a single combined measure that pooled blood sugar control, LDL cholesterol, systolic blood pressure, and depression scores, a difference the authors reported as statistically clear (P less than 0.001), including a 0.40-point greater improvement on the SCL-20 depression scale. Patients in the intervention group also had more adjustments to their treatment over the year, rated their quality of life as higher, were less disabled, and were more satisfied with their care for both their medical conditions and their depression.", "study": { "authors": "Katon, W. J., Lin, E. H. B., Von Korff, M., Ciechanowski, P., Ludman, E. J., Young, B., Peterson, D., Rutter, C. M., McGregor, M., & McCulloch, D.", "year": "2010", "title": "Collaborative Care for Patients with Depression and Chronic Illnesses", "journal": "New England Journal of Medicine", "citation": "New England Journal of Medicine, volume 363, pages 2611 to 2620", "doi": "10.1056/nejmoa1003955", "url": "https://doi.org/10.1056/nejmoa1003955" }, "sources": [ "Katon, W. J., Lin, E. H. B., Von Korff, M., Ciechanowski, P., Ludman, E. J., Young, B., Peterson, D., Rutter, C. M., McGregor, M., & McCulloch, D. (2010). Collaborative Care for Patients with Depression and Chronic Illnesses. New England Journal of Medicine, 363(27), 2611-2620. https://doi.org/10.1056/nejmoa1003955" ] }, { "id": "why-do-patients-drop-out-of-therapy-after-a-few-sessions", "question": "Why do patients drop out of therapy after a few sessions?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/why-do-patients-drop-out-of-therapy-after-a-few-sessions", "markdown": "https://www.asendar.com/gap/q/why-do-patients-drop-out-of-therapy-after-a-few-sessions.md", "published": "2026-10-16", "gapNumber": "669 studies representing 83,834 adult psychotherapy clients, across many diagnoses, treatment settings, provider types, and ways of defining dropout.", "shortAnswer": "About 1 in 5 adults leave therapy early. A 2012 meta-analysis of 669 studies and 83,834 clients put the average dropout rate at 19.7%. It was higher for younger clients, for people with personality or eating disorder diagnoses, and for those seen by trainee clinicians, and it did not depend on the type of therapy.", "keyFinding": "Joshua Swift and Roger Greenberg gathered 669 studies covering 83,834 adults in psychotherapy and asked one plain question. How many leave before the work is done? The average weighted dropout rate was 19.7%, with a 95% confidence interval of 18.7% to 20.7%. That is about 1 in every 5 clients. It is far below the 47% an older review had reported two decades earlier, but it is still a large share of people who start and do not stay. The rate was not the same everywhere. It shifted with the client's diagnosis and age, the provider's experience, the treatment setting, and even how each study defined dropout. Three groups stood out with higher rates: younger clients, people being treated for personality or eating disorders, and clients seen by trainee clinicians. One result matters for how a clinic reads this. Dropout did not vary with the type of therapy, with individual versus group format, or with most client demographics. The authors called for focused effort to hold on to the groups most likely to leave.", "study": { "authors": "Swift, J. K., & Greenberg, R. P.", "year": "2012", "title": "Premature Discontinuation in Adult Psychotherapy: A Meta-Analysis", "journal": "Journal of Consulting and Clinical Psychology", "citation": "Journal of Consulting and Clinical Psychology, volume 80, issue 4, pages 547 to 559", "doi": "10.1037/a0028226", "url": "https://doi.org/10.1037/a0028226" }, "sources": [ "Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80(4), 547-559. https://doi.org/10.1037/a0028226" ] }, { "id": "why-do-people-answer-mental-health-surveys-to-look-better-than-they-feel", "question": "Why do people answer mental health surveys to look better than they feel?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/why-do-people-answer-mental-health-surveys-to-look-better-than-they-feel", "markdown": "https://www.asendar.com/gap/q/why-do-people-answer-mental-health-surveys-to-look-better-than-they-feel.md", "published": "2026-10-16", "gapNumber": "3,502 soldiers from one US Army infantry brigade returning from Iraq in 2008 took the routine, named screen. 1,712 of them also answered the same questions on an anonymous survey.", "shortAnswer": "Many people shade their answers on mental health surveys so they look more okay than they feel. In one Army study, soldiers reported depression, PTSD, and suicidal thoughts 2 to 4 times more often on an anonymous survey than on their official, named screen. People tend to share more when they feel no one is judging them.", "keyFinding": "Christopher Warner and colleagues gave one brigade the routine Post-Deployment Health Assessment, which is linked to each soldier's name and record. Right after, a large group answered the same questions anonymously. The answers did not match. PTSD or depression went from 4.2% on the named screen to 12.1% on the anonymous survey. Suicidal thoughts went from 1.2% to 4.7%. Among soldiers who screened positive, 20.3% said they did not feel comfortable answering the official screen honestly, and 40.1% said unit leaders would have less confidence in them if they sought care. The authors concluded the routine screen misses most soldiers with significant mental health problems.", "study": { "authors": "Warner, C. H., and colleagues", "year": "2011", "title": "Importance of Anonymity to Encourage Honest Reporting in Mental Health Screening After Combat Deployment", "journal": "Archives of General Psychiatry", "citation": "Archives of General Psychiatry, volume 68, issue 10, starting page 1065", "doi": "10.1001/archgenpsychiatry.2011.112", "url": "https://doi.org/10.1001/archgenpsychiatry.2011.112" }, "sources": [ "Warner, C. H., et al. (2011). Importance of anonymity to encourage honest reporting in mental health screening after combat deployment. Archives of General Psychiatry, 68(10), 1065. https://doi.org/10.1001/archgenpsychiatry.2011.112", "Louzon, S. A., Bossarte, R., McCarthy, J. F., & Katz, I. R. (2016). Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? Psychiatric Services, 67(5), 517-522. https://doi.org/10.1176/appi.ps.201500149", "Busch, K. A., Fawcett, J., & Jacobs, D. G. (2003). Clinical correlates of inpatient suicide. Journal of Clinical Psychiatry, 64(1), 14-19. https://doi.org/10.4088/jcp.v64n0105", "Blanchard, M., & Farber, B. A. (2016). Lying in psychotherapy. Counselling Psychology Quarterly, 29(1), 90-112. https://doi.org/10.1080/09515070.2015.1085365", "Lucas, G. M., Gratch, J., King, A., & Morency, L.-P. (2014). It's only a computer: Virtual humans increase willingness to disclose. Computers in Human Behavior, 37, 94-100. https://doi.org/10.1016/j.chb.2014.04.043", "Lucas, G. M., Rizzo, A., Gratch, J., Scherer, S., Stratou, G., Boberg, J., & Morency, L.-P. (2017). Reporting mental health symptoms: Breaking down barriers to care with virtual human interviewers. Frontiers in Robotics and AI, 4, 51. https://doi.org/10.3389/frobt.2017.00051", "Weisband, S., & Kiesler, S. (1996). Self disclosure on computer forms: Meta-analysis and implications. Proceedings of CHI 1996, 3-10. https://doi.org/10.1145/238386.238387" ] }, { "id": "do-text-message-reminders-reduce-missed-appointments", "question": "Do text message reminders reduce missed appointments?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/do-text-message-reminders-reduce-missed-appointments", "markdown": "https://www.asendar.com/gap/q/do-text-message-reminders-reduce-missed-appointments.md", "published": "2026-10-15", "gapNumber": "18 reports in all, 8 randomized controlled trials and 10 controlled observational studies of text message reminders for health care appointments, across primary care and hospital outpatient clinics.", "shortAnswer": "Yes. A 2012 review of eight randomized trials found that text message reminders made patients clearly more likely to attend their appointments, a pooled effect of 1.48. The gain held across clinic types and whether the reminder went out one, two, or three days ahead. One small message, sent into the gap before the visit.", "keyFinding": "Rebecca Guy and colleagues gathered the research on text message reminders for health care appointments, published up to the middle of 2010. They found 18 reports in all: 8 randomized controlled trials and 10 controlled observational studies. The results across all 18 varied too much to combine into a single number, and that spread came from the observational studies. So the authors pooled only the randomized trials, the cleaner evidence. There, text message reminders gave a summary effect of 1.48, with a 95% confidence interval of 1.23 to 1.72. In plain terms, patients who got a reminder were clearly more likely to show up than patients who did not. The effect held across different kinds of clinics, and whether the reminder was sent 24, 48, or 72 or more hours before the appointment made little difference. The authors concluded that text message reminders are a simple and efficient way for a health service to improve attendance.", "study": { "authors": "Guy, R., Hocking, J., Wand, H., Stott, S., Ali, H., & Kaldor, J.", "year": "2012", "title": "How Effective Are Short Message Service Reminders at Increasing Clinic Attendance? A Meta-Analysis and Systematic Review", "journal": "Health Services Research", "citation": "Health Services Research, volume 47, issue 2, pages 614 to 632", "doi": "10.1111/j.1475-6773.2011.01342.x", "url": "https://doi.org/10.1111/j.1475-6773.2011.01342.x" }, "sources": [ "Guy, R., Hocking, J., Wand, H., Stott, S., Ali, H., & Kaldor, J. (2012). How effective are short message service reminders at increasing clinic attendance? A meta-analysis and systematic review. Health Services Research, 47(2), 614-632. https://doi.org/10.1111/j.1475-6773.2011.01342.x" ] }, { "id": "do-care-manager-phone-calls-between-visits-help-patients-with-depression", "question": "Do care manager phone calls between visits help patients with depression?", "pillar": "integration", "page": "https://www.asendar.com/gap/q/do-care-manager-phone-calls-between-visits-help-patients-with-depression", "markdown": "https://www.asendar.com/gap/q/do-care-manager-phone-calls-between-visits-help-patients-with-depression.md", "published": "2026-10-14", "gapNumber": "600 patients starting depression treatment in 7 group-model primary care clinics in Seattle, randomized to usual care, usual care plus telephone care management, or care management plus an 8-session telephone therapy program.", "shortAnswer": "Yes. In a 600-patient randomized trial, adding telephone care management to usual primary care raised the share of patients who rated their depression much improved, from 55% to 66%, and satisfaction from 29% to 47%. Pairing those calls with brief phone therapy helped more, reaching 80% much improved.", "keyFinding": "Gregory Simon and colleagues ran a three-group randomized trial with 600 patients who were just starting depression treatment in 7 group-model primary care clinics in Seattle. One group got usual primary care. A second got usual care plus telephone care management, which meant at least 3 outreach calls, feedback to the treating physician, and help coordinating care. A third got that care management plus a structured 8-session cognitive behavioral therapy program delivered by phone. Trained interviewers who did not know the group checked in at 6 weeks, 3 months, and 6 months. Patients took part at a high rate, 97% for care management and 93% for care management plus phone therapy. Care management on its own had smaller effects: more patients rated their depression much improved (66% versus 55%) and more were very satisfied (47% versus 29%), but its effect on average depression scores was not statistically significant. Adding phone therapy did more, with lower depression scores and 80% versus 55% rating themselves much improved. The authors called for active outreach to patients rather than waiting for them to return on their own.", "study": { "authors": "Simon, G. E., Ludman, E. J., Tutty, S., Operskalski, B., & Von Korff, M.", "year": "2004", "title": "Telephone Psychotherapy and Telephone Care Management for Primary Care Patients Starting Antidepressant Treatment: A Randomized Controlled Trial", "journal": "JAMA", "citation": "JAMA, volume 292, issue 8, pages 935 to 942", "doi": "10.1001/jama.292.8.935", "url": "https://doi.org/10.1001/jama.292.8.935" }, "sources": [ "Simon, G. E., Ludman, E. J., Tutty, S., Operskalski, B., & Von Korff, M. (2004). Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: A randomized controlled trial. JAMA, 292(8), 935-942. https://doi.org/10.1001/jama.292.8.935" ] }, { "id": "does-giving-therapists-progress-feedback-improve-patient-outcomes", "question": "Does giving therapists progress feedback improve patient outcomes?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/does-giving-therapists-progress-feedback-improve-patient-outcomes", "markdown": "https://www.asendar.com/gap/q/does-giving-therapists-progress-feedback-improve-patient-outcomes.md", "published": "2026-10-13", "gapNumber": "24 studies of the two most-studied routine outcome monitoring systems, the Partners for Change Outcome Management System and the Outcome Questionnaire System, in adult psychotherapy.", "shortAnswer": "Often, yes. A 2018 meta-analysis of 24 studies found that measuring a client's progress and feeding it back to the therapist during care beat treatment as usual in about two thirds of them. The gains were largest for clients heading for a poor outcome. Effects ranged from small to moderate.", "keyFinding": "Michael Lambert, Jason Whipple, and Maria Kleinstäuber reviewed and pooled the research on routine outcome monitoring. That means measuring a client's progress on a short questionnaire during care and showing the result to the therapist while treatment is still going on. They focused on the two most studied systems, the Partners for Change Outcome Management System and the Outcome Questionnaire System, and found 24 suitable studies. About two thirds of those studies found that therapy with routine outcome monitoring beat treatment as usual delivered by the same therapists. The average effects ranged from small to moderate. The biggest gains went to clients who were predicted to have a poor outcome. For them, feedback cut the rate of getting worse and nearly doubled the rate of clinically significant or reliable change. The authors are clear about the mechanism: the feedback helps a therapist notice a client who is not responding, and it opens a conversation about what to change.", "study": { "authors": "Lambert, M. J., Whipple, J. L., & Kleinstäuber, M.", "year": "2018", "title": "Collecting and Delivering Progress Feedback: A Meta-Analysis of Routine Outcome Monitoring", "journal": "Psychotherapy", "citation": "Psychotherapy, volume 55, issue 4, pages 520 to 537", "doi": "10.1037/pst0000167", "url": "https://doi.org/10.1037/pst0000167" }, "sources": [ "Lambert, M. J., Whipple, J. L., & Kleinstäuber, M. (2018). Collecting and Delivering Progress Feedback: A Meta-Analysis of Routine Outcome Monitoring. Psychotherapy, 55(4), 520-537. https://doi.org/10.1037/pst0000167" ] }, { "id": "does-measurement-based-care-improve-depression-treatment", "question": "Does measurement-based care improve depression treatment?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/does-measurement-based-care-improve-depression-treatment", "markdown": "https://www.asendar.com/gap/q/does-measurement-based-care-improve-depression-treatment.md", "published": "2026-10-13", "gapNumber": "120 outpatients with moderate to severe major depression at a single center in Beijing, randomized to measurement-based care (61) or standard care (59) for 24 weeks.", "shortAnswer": "In one strong trial, yes. When regular rating-scale scores and a guideline drove each treatment decision, 73.8% of outpatients with moderate to severe depression reached remission in 24 weeks, compared with 28.8% under standard care. They also got there about nine weeks sooner. It is one trial, so treat it as a strong signal.", "keyFinding": "Tong Guo and colleagues compared two ways of making treatment decisions for depression. In measurement-based care, decisions followed a guideline and regular scores from standard rating scales. In standard care, decisions were left to the clinician's own judgment. Both groups had the same short list of antidepressants to choose from, so the difference was how decisions were made, not what was available. Raters who judged the outcomes did not know which group a patient was in. With measurement-based care, 86.9% of patients responded (their depression score fell by at least half), compared with 62.7% in standard care. Remission was 73.8% compared with 28.8%. Response came sooner (5.6 weeks versus 11.6 weeks), and so did remission (10.2 weeks versus 19.2 weeks). The measurement-based group had more treatment adjustments, 44 compared with 23. Rates of leaving the study and side effects did not differ between the groups.", "study": { "authors": "Guo, T., Xiang, Y.-T., Xiao, L., Hu, C.-Q., Chiu, H. F. K., Ungvari, G. S., Correll, C. U., Lai, K. Y. C., Feng, L., Geng, Y., Feng, Y., & Wang, G.", "year": "2015", "title": "Measurement-Based Care Versus Standard Care for Major Depression: A Randomized Controlled Trial With Blind Raters", "journal": "American Journal of Psychiatry", "citation": "American Journal of Psychiatry, volume 172, issue 10, pages 1004 to 1013", "doi": "10.1176/appi.ajp.2015.14050652", "url": "https://doi.org/10.1176/appi.ajp.2015.14050652" }, "sources": [ "Guo, T., Xiang, Y.-T., Xiao, L., Hu, C.-Q., Chiu, H. F. K., Ungvari, G. S., Correll, C. U., Lai, K. Y. C., Feng, L., Geng, Y., Feng, Y., & Wang, G. (2015). Measurement-Based Care Versus Standard Care for Major Depression: A Randomized Controlled Trial With Blind Raters. American Journal of Psychiatry, 172(10), 1004-1013. https://doi.org/10.1176/appi.ajp.2015.14050652" ] }, { "id": "does-collaborative-care-work-for-depression-over-the-long-term", "question": "Does collaborative care work for depression over the long term?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/does-collaborative-care-work-for-depression-over-the-long-term", "markdown": "https://www.asendar.com/gap/q/does-collaborative-care-work-for-depression-over-the-long-term.md", "published": "2026-10-12", "gapNumber": "79 randomized controlled trials (90 comparisons) with 24,308 participants, comparing collaborative care with usual care for depression or anxiety.", "shortAnswer": "Yes, through long-term follow-up, but not indefinitely. A Cochrane review of 79 randomized trials and 24,308 people found collaborative care improved depression more than usual care at short, medium, and long-term follow-up. In the very long term the benefit was no longer clear, so a clinic needs a plan for what comes after the program.", "keyFinding": "Janine Archer and colleagues pooled every randomized trial they could find that compared collaborative care with usual care for depression or anxiety. Collaborative care is a team model built on chronic disease management: a care manager, the primary care clinician, and a mental health specialist share the work and follow each patient over time. The review covered 79 trials and 24,308 people. For adults with depression, collaborative care led to greater improvement than usual care in the short term (standardised mean difference -0.34, risk ratio 1.32), the medium term (SMD -0.28, RR 1.31), and the long term (SMD -0.35, RR 1.29). In the very long term the difference was no longer statistically clear (RR 1.12, with a confidence interval of 0.98 to 1.27 that includes no effect). Anxiety showed the same pattern through the long term (RR 1.50, 1.41, and 1.26), and no trial followed anxiety into the very long term. Patients in collaborative care also reported better mental health quality of life and more satisfaction with their care. The trials varied in their risk of bias.", "study": { "authors": "Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C., & Coventry, P.", "year": "2012", "title": "Collaborative care for depression and anxiety problems", "journal": "Cochrane Database of Systematic Reviews", "citation": "Cochrane Database of Systematic Reviews, issue 10, article CD006525", "doi": "10.1002/14651858.CD006525.pub2", "url": "https://doi.org/10.1002/14651858.CD006525.pub2" }, "sources": [ "Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C., & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 2012(10), CD006525. https://doi.org/10.1002/14651858.CD006525.pub2" ] }, { "id": "does-crying-actually-make-you-feel-better", "question": "Does crying actually make you feel better?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/does-crying-actually-make-you-feel-better", "markdown": "https://www.asendar.com/gap/q/does-crying-actually-make-you-feel-better.md", "published": "2026-09-26", "gapNumber": "106 adults, followed for four weeks, who logged 315 crying episodes in the moment on their phones. Mood was checked right after each cry and again at 15, 30, and 60 minutes, and at the end of the day.", "shortAnswer": "Not always. A 2026 study that tracked real crying episodes found crying does not reliably lift your mood on its own. What matters is why you cried. Tears from feeling overwhelmed often left people feeling worse for a while, while tears from moving moments eased some distress instead.", "keyFinding": "Stefan Stieger, Hannah Graf, and Sophie Biebl followed 106 adults for four weeks and had them record each time they cried, in the moment, on their phones. This is called event-based experience sampling, which means the data came from real life as it happened rather than from a lab. People logged 315 crying episodes as they occurred, noting what set the tears off, how intense they were, and how they felt. The team then checked in on mood again 15, 30, and 60 minutes later, and once more at the end of the day. Crying was common, about 5 episodes per person over the month, and women cried more often, longer, and more intensely than men. The headline finding was that crying did not reliably make people feel better. The effect depended on why they cried. When tears came after feeling overwhelmed or strained, people tended to report lower positive mood and higher negative mood afterward. When tears came in response to something moving, such as a film or a piece of music, negative mood tended to ease. So relief was real for some episodes and simply absent for others.", "study": { "authors": "Stieger, S., Graf, H., & Biebl, S.", "year": "2026", "title": "Effects of Crying on Affect: An Event-based Experience Sampling Study of Adult Emotional Crying", "journal": "Collabra: Psychology", "citation": "Collabra: Psychology, volume 12, issue 1, article 157541", "doi": "10.1525/collabra.157541", "url": "https://doi.org/10.1525/collabra.157541" }, "sources": [ "Stieger, S., Graf, H., & Biebl, S. (2026). Effects of Crying on Affect: An Event-based Experience Sampling Study of Adult Emotional Crying. Collabra: Psychology, 12(1), 157541. https://doi.org/10.1525/collabra.157541" ] }, { "id": "is-it-normal-to-feel-adrift-between-therapy-sessions", "question": "Is it normal to feel adrift between therapy sessions?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/is-it-normal-to-feel-adrift-between-therapy-sessions", "markdown": "https://www.asendar.com/gap/q/is-it-normal-to-feel-adrift-between-therapy-sessions.md", "published": "2026-09-25", "gapNumber": "211 adults, 161 women and 50 men, on a waiting list for pain management at a regional NHS hospital in the south east of England. Standard wellbeing measures were taken at the start of the wait, then again at three months and six months.", "shortAnswer": "Yes. Feeling adrift or low between therapy sessions is common. Research on people waiting for care found that distress like anxiety and low mood tends to stay high across a long wait rather than fade on its own. The gap is an active stretch, and it is easier with support and a small plan.", "keyFinding": "Lydia Tidmarsh and her colleagues at the University of Reading and the Royal Berkshire Hospital followed 211 adults who were on a waiting list for pain management at a regional NHS hospital in the south east of England. There were 161 women and 50 men. It was a longitudinal survey, which means the same people were checked more than once over time. The team measured four things at the start of the wait, then again at three months and six months: depression, anxiety, pain catastrophizing, which means expecting the worst about pain, and pain self-efficacy, which means confidence in coping. The waits were long. People waited about 166 days on average just to be sorted into care, and about 354 days for a first treatment appointment. Across that whole stretch, distress stayed high. Average scores sat in the clinically meaningful range for depression, anxiety, and catastrophizing, and confidence in coping stayed low, for the length of the wait. One measure, confidence in coping, rose a little over time, but the change was small and the level stayed in the range where support is needed. The authors concluded that the distress was persistent and entrenched, not something the wait resolved on its own.", "study": { "authors": "Tidmarsh, L. V., Harrison, R., Wilkinson, H., Harrington, M., Ravindran, D., Norwood, S., & Finlay, K. A.", "year": "2026", "title": "The persistence of psychological distress while waiting for pain management", "journal": "British Journal of Pain", "citation": "British Journal of Pain", "doi": "10.1177/20494637251377761", "url": "https://doi.org/10.1177/20494637251377761" }, "sources": [ "Tidmarsh, L. V., Harrison, R., Wilkinson, H., Harrington, M., Ravindran, D., Norwood, S., & Finlay, K. A. (2026). The persistence of psychological distress while waiting for pain management. British Journal of Pain. https://doi.org/10.1177/20494637251377761" ] }, { "id": "do-eyeshades-and-headphones-change-a-plant-medicine-session", "question": "Do eyeshades and headphones change a plant medicine session?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/do-eyeshades-and-headphones-change-a-plant-medicine-session", "markdown": "https://www.asendar.com/gap/q/do-eyeshades-and-headphones-change-a-plant-medicine-session.md", "published": "2026-09-24", "gapNumber": "Ten adults in a psilocybin study for smoking cessation, each doing sessions with different music. This page describes the study's design and direction, not exact effect sizes, because the source could not be opened directly to confirm those numbers this run.", "shortAnswer": "Eyeshades and headphones are standard in plant medicine therapy. Eyeshades turn your gaze inward, and headphones carry a guiding music program. Direct evidence that the setup itself changes a session is thin. In one small randomized study, even swapping the music genre inside that setup produced no clear, reliable difference.", "keyFinding": "Justin Strickland, Albert Garcia-Romeu, and Matthew Johnson at Johns Hopkins ran a small randomized study inside the classic setup of plant medicine therapy. In that setup, a person lies down, puts on eyeshades to block the room, and listens to a curated playlist through headphones, so their attention turns inward. The team kept that frame the same for everyone and changed one thing: the music. Ten adults taking part in a psilocybin study for smoking took part in sessions with two different music styles, a Western classical playlist and an overtone-based playlist built from sustained tones and world instruments. The order was counterbalanced, meaning some people heard one style first and some the other, so the order itself would not skew the result. For a later session, each person picked the playlist they preferred, and six of the ten chose the overtone-based one. Scores for a mystical-type experience tended to run a little higher during the overtone-based sessions, and the smoking result leaned the same way. But the differences between the two music styles were not statistically reliable, meaning they were small enough that chance could explain them. So the study is best read as a careful first look, not a verdict. It tells us people had a preference and there was a gentle lean, inside a setup that was held constant the whole time.", "study": { "authors": "Strickland, J. C., Garcia-Romeu, A., & Johnson, M. W.", "year": "2021", "title": "Set and Setting: A Randomized Study of Different Musical Genres in Supporting Psychedelic Therapy", "journal": "ACS Pharmacology & Translational Science", "citation": "ACS Pharmacology & Translational Science, volume 4, issue 2, pages 472 to 478", "doi": "10.1021/acsptsci.0c00187", "url": "https://doi.org/10.1021/acsptsci.0c00187" }, "sources": [ "Strickland, J. C., Garcia-Romeu, A., & Johnson, M. W. (2021). Set and Setting: A Randomized Study of Different Musical Genres in Supporting Psychedelic Therapy. ACS Pharmacology & Translational Science, 4(2), 472-478. https://doi.org/10.1021/acsptsci.0c00187" ] }, { "id": "does-talking-about-change-actually-build-your-motivation", "question": "Does talking about change actually build your motivation?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/does-talking-about-change-actually-build-your-motivation", "markdown": "https://www.asendar.com/gap/q/does-talking-about-change-actually-build-your-motivation.md", "published": "2026-09-23", "gapNumber": "Twenty studies of motivational interviewing for mental health problems, in people with mood, anxiety, psychotic, and eating conditions and mixes of these. This page describes the review's design and direction, not exact pooled numbers, because the source could not be opened to confirm them this run.", "shortAnswer": "Not the way you might think. When researchers pooled 20 studies of motivational interviewing for mental health, the approach did not raise people's motivation more than other methods did. What it did improve was engagement, staying involved in the work. Talking about change seems to help you show up, not just want it.", "keyFinding": "In 2015, Mia Romano and Lorna Peters at Macquarie University set out to answer a question that sits underneath a lot of therapy. When a conversation about change seems to help, what is actually doing the work? They focused on motivational interviewing, a style of talking that is built to draw out a person's own reasons for change. They gathered the research on how it works for mental health, and 20 studies met their bar, covering people with mood, anxiety, psychotic, and eating conditions, and mixes of these. They looked at the parts the method is meant to move: a person's motivation and confidence, their resistance or pushback, and their engagement, meaning how involved they stayed in the work. The result was honest and a little surprising. Motivational interviewing did not raise people's motivation more than the approaches it was compared against. Where it did show an edge was engagement. People given this style tended to stay more involved in their treatment. The authors were careful to call this an early read. The studies were few and varied, so the pattern is a lead worth following, not a settled account of why talking about change helps.", "study": { "authors": "Romano, M., & Peters, L.", "year": "2015", "title": "Evaluating the mechanisms of change in motivational interviewing in the treatment of mental health problems: A review and meta-analysis", "journal": "Clinical Psychology Review", "citation": "Clinical Psychology Review, volume 38, pages 1 to 12", "doi": "10.1016/j.cpr.2015.02.008", "url": "https://doi.org/10.1016/j.cpr.2015.02.008" }, "sources": [ "Romano, M., & Peters, L. (2015). Evaluating the mechanisms of change in motivational interviewing in the treatment of mental health problems: A review and meta-analysis. Clinical Psychology Review, 38, 1-12. https://doi.org/10.1016/j.cpr.2015.02.008" ] }, { "id": "why-do-old-memories-come-up-during-a-session", "question": "Why do old memories come up during a session?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/why-do-old-memories-come-up-during-a-session", "markdown": "https://www.asendar.com/gap/q/why-do-old-memories-come-up-during-a-session.md", "published": "2026-09-22", "gapNumber": "Healthy adult volunteers in a laboratory fear-conditioning experiment, measured with the eyeblink startle response. This was a study of a simple learned fear in the lab, not of the personal memories that surface in a therapy or plant medicine session.", "shortAnswer": "Old memories often surface during a session because a session reactivates them, and a reactivated memory can become open to change rather than just replay. A 2012 fear-memory study found that retrieval alone does not update a memory. It is the surprise of a new experience during retrieval that opens the door.", "keyFinding": "In 2012, Dieuwke Sevenster, Tom Beckers, and Merel Kindt set out to test a simple but important idea about memory. When a memory comes back to mind, does it automatically become open to change? To find out, they first taught healthy volunteers to fear a harmless image by pairing it with a mild electric shock, a standard laboratory method. The next day, they brought that memory back in different ways. Sometimes they showed the image and nothing happened, which broke the person's expectation of a shock. Other times they arranged things so there was no surprise at all. They tracked fear with the eyeblink startle response, a quick automatic flinch that rises when a person is on edge. The result was clear. Simply calling the memory back to mind was not enough to change it. The memory only became open to updating when the moment carried a surprise, a mismatch between what the person expected and what actually happened. The researchers called this mismatch a prediction error. Without it, the old fear stayed locked in place. With it, the memory softened and could be reshaped.", "study": { "authors": "Sevenster, D., Beckers, T., & Kindt, M.", "year": "2012", "title": "Retrieval per se is not sufficient to trigger reconsolidation of human fear memory", "journal": "Neurobiology of Learning and Memory", "citation": "Neurobiology of Learning and Memory, volume 97, issue 3, pages 338 to 345", "doi": "10.1016/j.nlm.2012.01.009", "url": "https://doi.org/10.1016/j.nlm.2012.01.009" }, "sources": [ "Sevenster, D., Beckers, T., & Kindt, M. (2012). Retrieval per se is not sufficient to trigger reconsolidation of human fear memory. Neurobiology of Learning and Memory, 97(3), 338-345. https://doi.org/10.1016/j.nlm.2012.01.009" ] }, { "id": "how-do-i-cope-with-waiting-for-my-next-therapy-appointment", "question": "How do I cope with waiting for my next therapy appointment?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/how-do-i-cope-with-waiting-for-my-next-therapy-appointment", "markdown": "https://www.asendar.com/gap/q/how-do-i-cope-with-waiting-for-my-next-therapy-appointment.md", "published": "2026-09-21", "gapNumber": "None. This is a conceptual paper that names and describes a pattern. It did not count people or test coping methods.", "shortAnswer": "Waiting for your next appointment can bring real distress, even when you know help is coming. A 2026 conceptual paper named this pattern waiting anxiety. It describes racing thoughts, a tense body, and feelings that are hard to settle during a certain, positive wait. Naming it is the first step to easing it.", "keyFinding": "Waqar Husain and Haitham Jahrami set out to name something that had gone mostly unnamed. Their paper is a conceptual account, not an experiment. It does not count participants or test treatments. Instead it draws on existing theory and lived description to describe a pattern the authors call waiting anxiety. Here is the puzzle they start from. Anxiety is usually tied to a threat, to the chance that something bad might happen. But people often feel keyed up and unsettled while waiting for something good that is almost sure to arrive, like an approaching wedding, a confirmed promotion, or an approved visa. The outcome is positive. The outcome is basically certain. And still the wait is hard. The authors describe three threads that run through this kind of distress. The first is cognitive rumination, the mind circling the same thoughts about the wait. The second is physiological arousal, the body staying switched on and tense. The third is difficulty with emotion regulation, a struggle to settle those feelings back down. They argue this paradoxical distress is common, under-recognized, and worth taking seriously on its own terms. Because this is a framework rather than a trial, it maps the experience and offers language for it. It does not measure how many people feel it, and it does not prove that any one coping method eases it.", "study": { "authors": "Husain, W., and Jahrami, H.", "year": "2026", "title": "Waiting Anxiety: A Phenomenological Account of Anticipatory Anxiety During Rationally Certain and Pleasant Outcome Waiting", "journal": "Psychiatry International", "citation": "Psychiatry International, volume 7, issue 2, article 68", "doi": "10.3390/psychiatryint7020068", "url": "https://doi.org/10.3390/psychiatryint7020068" }, "sources": [ "Husain, W., & Jahrami, H. (2026). Waiting Anxiety: A Phenomenological Account of Anticipatory Anxiety During Rationally Certain and Pleasant Outcome Waiting. Psychiatry International, 7(2), 68. https://doi.org/10.3390/psychiatryint7020068" ] }, { "id": "does-time-feel-different-during-a-plant-medicine-session", "question": "Does time feel different during a plant medicine session?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/does-time-feel-different-during-a-plant-medicine-session", "markdown": "https://www.asendar.com/gap/q/does-time-feel-different-during-a-plant-medicine-session.md", "published": "2026-09-19", "gapNumber": "Twelve healthy adult volunteers, each tested under both placebo and psilocybin in a double-blind laboratory design. This was a small study of timing tasks, not a study of a therapy session.", "shortAnswer": "Yes, many people feel time stretch, blur, or loosen during a plant medicine session, and a small controlled study backs that up. When people were given psilocybin, their sense of longer stretches of time, over roughly two to three seconds, drifted off, while very short intervals stayed accurate.", "keyFinding": "In 2007, Marc Wittmann, Olivia Carter, Felix Hasler, Franz Vollenweider, and their colleagues published this study in the Journal of Psychopharmacology. They set out to test something people had long described but few had measured: does a plant medicine actually change how the brain handles time? Twelve healthy adults took part in a careful double-blind design, which means that on any given session neither they nor the testers knew whether they had received psilocybin or a placebo. Each person worked through a set of timing tasks. In one, they tried to reproduce a time interval they had just been shown. In another, they tapped along in time with a steady beat. In a third, they simply tapped at whatever pace felt natural. The results pointed in one clear direction. Psilocybin threw off timing for longer stretches. People became less accurate at reproducing intervals longer than about two to three seconds, and less able to keep in step with beats spaced more than about two seconds apart. Very short intervals were left largely intact. People also tapped more slowly at their own natural pace. The disruption was specific to the longer durations, the kind that lean on attention and holding a length of time in mind.", "study": { "authors": "Wittmann, M., Carter, O., Hasler, F., Cahn, B. R., Grimberg, U., Spring, P., Hell, D., Flohr, H., & Vollenweider, F. X.", "year": "2007", "title": "Effects of psilocybin on time perception and temporal control of behaviour in humans", "journal": "Journal of Psychopharmacology", "citation": "Journal of Psychopharmacology, volume 21, issue 1, pages 50 to 64", "doi": "10.1177/0269881106065859", "url": "https://doi.org/10.1177/0269881106065859" }, "sources": [ "Wittmann, M., Carter, O., Hasler, F., Cahn, B. R., Grimberg, U., Spring, P., Hell, D., Flohr, H., & Vollenweider, F. X. (2007). Effects of psilocybin on time perception and temporal control of behaviour in humans. Journal of Psychopharmacology, 21(1), 50-64. https://doi.org/10.1177/0269881106065859" ] }, { "id": "can-a-positive-mindset-before-a-session-improve-it", "question": "Can a positive mindset before a session improve it?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/can-a-positive-mindset-before-a-session-improve-it", "markdown": "https://www.asendar.com/gap/q/can-a-positive-mindset-before-a-session-improve-it.md", "published": "2026-09-18", "gapNumber": "Adults receiving cognitive behavioral therapy for generalized anxiety disorder in a clinical trial, with their outcome expectation measured over and over across treatment. This page describes the study's design and direction, not an exact participant count, because the source could not be opened to confirm that number this run.", "shortAnswer": "A hopeful mindset does appear to help, but it is not a switch you flip alone. In therapy for anxiety, people's belief that treatment would work tended to rise over the course of care, and it rose most alongside early relief and a steady therapist. Hope matters, and it also grows.", "keyFinding": "In 2021, Andreea Vîslă, Michael Constantino, and Christoph Flückiger published this study in the journal Psychotherapy. They followed adults receiving cognitive behavioral therapy for generalized anxiety disorder and measured, again and again across treatment, one thing: how much each person expected the therapy to help. Researchers call this outcome expectation, and it is the closest the research has to a person's going in mindset. Using multilevel models that tracked each person over time, the team found that outcome expectation did not stay flat. On average it rose steadily from the start of treatment to the end. They also looked at what shaped it. People who came in with heavier depression tended to start with lower expectation. Early change mattered too: reductions in anxiety and overall severity in the first sessions, and early shifts in how capable people felt, were tied to the path each person's expectation took. And the therapist counted. There were real differences between therapists in how much their clients' expectation changed, which means a mindset is not built by the client alone. The honest limit is that this is one anxiety trial, and the study measured what predicts expectation rather than proving that expectation causes a better result.", "study": { "authors": "Vîslă, A., Constantino, M. J., & Flückiger, C.", "year": "2021", "title": "Predictors of change in patient treatment outcome expectation during cognitive-behavioral psychotherapy for generalized anxiety disorder", "journal": "Psychotherapy", "citation": "Psychotherapy, volume 58, issue 2, pages 219 to 229", "doi": "10.1037/pst0000371", "url": "https://doi.org/10.1037/pst0000371" }, "sources": [ "Vîslă, A., Constantino, M. J., & Flückiger, C. (2021). Predictors of change in patient treatment outcome expectation during cognitive-behavioral psychotherapy for generalized anxiety disorder. Psychotherapy, 58(2), 219-229. https://doi.org/10.1037/pst0000371" ] }, { "id": "should-i-know-what-i-want-to-change-before-starting-therapy", "question": "Should I know what I want to change before starting therapy?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/should-i-know-what-i-want-to-change-before-starting-therapy", "markdown": "https://www.asendar.com/gap/q/should-i-know-what-i-want-to-change-before-starting-therapy.md", "published": "2026-09-17", "gapNumber": "None. This is a critical editorial, not a study of participants. It weighs decades of research, most of it on smoking, where the model was built.", "shortAnswer": "Not necessarily. It helps to have a rough sense of direction, but you do not need it all figured out first. A leading researcher argued the tidy stages of change model, which says you must reach a ready to act stage before you begin, does not hold up. Uncertainty is a normal place to start.", "keyFinding": "In 2005, the addiction researcher Robert West wrote a short, pointed editorial in the journal Addiction. His target was the transtheoretical model, better known as the stages of change. That model sorts people into steps, from not yet thinking about change, to thinking about it, to getting ready, to acting, to keeping it up. It became one of the most widely taught ideas in health care. West argued it should be set aside. His main objection was the idea of a stage itself. The model splits a smooth, shifting thing into boxes, and the lines between the boxes are drawn at arbitrary places, often by a clock. Planning to change in the next thirty days puts you in one stage, the next six months in another, with nothing real marking the border. He also pointed out that people in the grip of an addiction rarely hold the steady, coherent plans the model assumes. Change is often sudden and unplanned rather than a march through neat steps. And after decades of study, mostly in smoking, he found little evidence that matching help to a person's stage worked better than help that ignored stages. His suggestion was plain. Go back to simpler questions, how much a person wants to change and how able they feel to do it, or build a better model.", "study": { "authors": "West, R.", "year": "2005", "title": "Time for a change: putting the Transtheoretical (Stages of Change) Model to rest", "journal": "Addiction", "citation": "Addiction, volume 100, pages 1036 to 1039", "doi": "10.1111/j.1360-0443.2005.01139.x", "url": "https://doi.org/10.1111/j.1360-0443.2005.01139.x" }, "sources": [ "West, R. (2005). Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction, 100(8), 1036-1039. https://doi.org/10.1111/j.1360-0443.2005.01139.x" ] }, { "id": "does-the-time-between-therapy-sessions-affect-how-well-it-works", "question": "Does the time between therapy sessions affect how well it works?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/does-the-time-between-therapy-sessions-affect-how-well-it-works", "markdown": "https://www.asendar.com/gap/q/does-the-time-between-therapy-sessions-affect-how-well-it-works.md", "published": "2026-09-16", "gapNumber": "21,488 university counseling center clients, tracked session by session over 17 years", "shortAnswer": "Often, yes. A large 2015 study tracked more than 21,000 people in real therapy and found that those seen weekly tended to recover faster than those seen every two weeks. Shorter gaps were linked to quicker progress. It measured speed of recovery, not a promise, and people were not randomly assigned.", "keyFinding": "David Erekson, Michael Lambert, and Dennis Eggett took a plain question and answered it with an unusually large pile of real-world data. They pulled 17 years of records from a university counseling center, covering 21,488 students who came in for therapy. Every client filled out a short well-being questionnaire, the Outcome Questionnaire 45, at the start of each session, so the researchers could watch progress session by session rather than guess at it. Then they compared people who were seen about once a week with people who were seen about once every two weeks. The pattern was clear. Clients seen weekly tended to recover faster than clients seen every two weeks. They reached the same kind of improvement in fewer weeks on the calendar. The authors were careful to frame this as speed. Weekly clients got better sooner, not necessarily to a higher final point. And because this was therapy as it actually happened and not a controlled trial, people were not randomly assigned to a schedule. The team could measure the link between shorter gaps and faster recovery, but it could not prove that the schedule alone caused it. The group was also mostly young university students, so the exact numbers may not carry over to everyone.", "study": { "authors": "Erekson, D. M., Lambert, M. J., and Eggett, D. L.", "year": "2015", "title": "The relationship between session frequency and psychotherapy outcome in a naturalistic setting", "journal": "Journal of Consulting and Clinical Psychology", "citation": "Journal of Consulting and Clinical Psychology, volume 83, issue 6, pages 1097 to 1107", "doi": "10.1037/a0039774", "url": "https://doi.org/10.1037/a0039774" }, "sources": [ "Erekson, D. M., Lambert, M. J., & Eggett, D. L. (2015). The relationship between session frequency and psychotherapy outcome in a naturalistic setting. Journal of Consulting and Clinical Psychology, 83(6), 1097-1107. https://doi.org/10.1037/a0039774" ] }, { "id": "how-do-i-make-sense-of-what-came-up-in-a-session", "question": "How do I make sense of what came up in a session?", "pillar": "integration", "page": "https://www.asendar.com/gap/q/how-do-i-make-sense-of-what-came-up-in-a-session", "markdown": "https://www.asendar.com/gap/q/how-do-i-make-sense-of-what-came-up-in-a-session.md", "published": "2026-09-15", "gapNumber": "developed across several rounds, with a final validation sample of 600 adults", "shortAnswer": "You make sense of it through integration, the plain and repeatable work of processing an experience after it ends. A 2022 study mapped this into two scales, one for what you do, like journaling and talking it over, and one for how integrated you come to feel inside. The doing and the feeling are closely linked.", "keyFinding": "Tomas Frymann, David Yaden, and their colleagues set out to do something that sounds simple and had not really been done. They wanted a plain way to measure integration, the after-the-session work of making sense of an experience and carrying it into ordinary life. They reviewed what the field had written, interviewed people about their own process, and tested question after question across several rounds, ending with a validation study of 600 adults. The work produced two short scales that measure two different things. The first, the Integration Engagement Scale, measures what a person actually does: talking the experience through, writing about it, sitting in silent reflection, reading or listening to things that help them think it over, and spending time in nature. The second, the Experienced Integration Scale, measures how integrated a person feels on the inside, the sense that what came up has been understood and woven into their life rather than left loose. Both scales held together well as measures, with Cronbach's alpha values of 0.90 and 0.92, a sign that the questions in each one were tapping a single consistent thing. And the two scales were closely linked to each other. People who did more of the integration work tended to also feel more integrated. The authors were careful about what they had built. These are tools for measuring integration, not proof that any single practice makes a person feel whole.", "study": { "authors": "Frymann, T., Whitney, S., Yaden, D. B., and Lipson, J.", "year": "2022", "title": "The Psychedelic Integration Scales: Tools for Measuring Psychedelic Integration Behaviors and Experiences", "journal": "Frontiers in Psychology", "citation": "Frontiers in Psychology, volume 13, article 863247", "doi": "10.3389/fpsyg.2022.863247", "url": "https://doi.org/10.3389/fpsyg.2022.863247" }, "sources": [ "Frymann, T., Whitney, S., Yaden, D. B., & Lipson, J. (2022). The Psychedelic Integration Scales: Tools for Measuring Psychedelic Integration Behaviors and Experiences. Frontiers in Psychology, 13, 863247. https://doi.org/10.3389/fpsyg.2022.863247" ] }, { "id": "why-do-i-cry-during-a-therapy-session", "question": "Why do I cry during a therapy session?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/why-do-i-cry-during-a-therapy-session", "markdown": "https://www.asendar.com/gap/q/why-do-i-cry-during-a-therapy-session.md", "published": "2026-09-14", "gapNumber": "1,404 adults across two online samples of 623 and 781 people, ages 18 to 81", "shortAnswer": "Crying in a session is a normal response to strong feeling, not a sign of weakness. Research on adults links how readily you cry to your attachment style and your beliefs about crying. Tears often show up when you finally feel safe enough to let something surface.", "keyFinding": "Abigail Millings and her colleagues studied how readily adults cry and why it varies so much from one person to the next. They ran two large online surveys, one with 623 people and one with 781, with ages spread from 18 to 81. Each person answered questions about their attachment style, their attitudes toward crying, and how easily they cried across different situations. Two patterns held across both samples. People higher in attachment anxiety, who tend to worry about closeness and rejection, cried more readily. People higher in attachment avoidance, who tend toward distance and self-reliance, cried less readily. The team also found this was not only about the feeling itself. A person's beliefs about crying helped explain the link. The views that crying is healthy and that crying is something you can control accounted for much of the gap between the groups. In plain terms, how easily you cry is shaped by how safe closeness feels to you, and by what you believe crying means.", "study": { "authors": "Millings, A., Hepper, E. G., Hart, C. M., Swift, L., and Rowe, A. C.", "year": "2016", "title": "Holding Back the Tears: Individual Differences in Adult Crying Proneness Reflect Attachment Orientation and Attitudes to Crying", "journal": "Frontiers in Psychology", "citation": "Frontiers in Psychology, volume 7, article 1003", "doi": "10.3389/fpsyg.2016.01003", "url": "https://doi.org/10.3389/fpsyg.2016.01003" }, "sources": [ "Millings, A., Hepper, E. G., Hart, C. M., Swift, L., & Rowe, A. C. (2016). Holding Back the Tears: Individual Differences in Adult Crying Proneness Reflect Attachment Orientation and Attitudes to Crying. Frontiers in Psychology, 7, 1003. https://doi.org/10.3389/fpsyg.2016.01003" ] }, { "id": "does-being-motivated-for-therapy-change-how-well-it-works", "question": "Does being motivated for therapy change how well it works?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/does-being-motivated-for-therapy-change-how-well-it-works", "markdown": "https://www.asendar.com/gap/q/does-being-motivated-for-therapy-change-how-well-it-works.md", "published": "2026-09-13", "gapNumber": "A meta-analysis pooling studies of motivational interviewing that measured both what happened inside sessions and how people did afterward", "shortAnswer": "In part, yes, but not as simply as it sounds. Being motivated helps you show up, speak openly, and do the work between sessions, and that engagement is part of what helps. Still, research finds the link between how motivated you feel and how well therapy turns out is real but modest, and often mixed.", "keyFinding": "Brian Pace and his colleagues gathered studies of motivational interviewing, a counseling style built to draw out a person's own reasons for change, and pooled them to test one idea at the center of the method. The claim is that the therapist's approach pulls more change talk from the client, the client's own words in favor of change, and that this in-session motivation is what carries better results later. When the studies were combined, the pieces lined up in the direction the theory predicts, but the connections were mostly small. The evidence that a client's in-session motivation reliably passed through to a better final outcome was weak and mixed rather than a clean yes. The honest read is that motivation looks like part of the picture, not a lever that settles how therapy turns out.", "study": { "authors": "Pace, B. T., Dembe, A., Soma, C. S., Baldwin, S. A., Atkins, D. C., & Imel, Z. E.", "year": "2017", "title": "A multivariate meta-analysis of motivational interviewing process and outcome", "journal": "Psychology of Addictive Behaviors", "citation": "Psychology of Addictive Behaviors, volume 31, pages 524 to 533", "doi": "10.1037/adb0000280", "url": "https://doi.org/10.1037/adb0000280" }, "sources": [ "Pace, B. T., Dembe, A., Soma, C. S., Baldwin, S. A., Atkins, D. C., & Imel, Z. E. (2017). A multivariate meta-analysis of motivational interviewing process and outcome. Psychology of Addictive Behaviors, 31(5), 524-533. https://doi.org/10.1037/adb0000280" ] }, { "id": "how-do-i-keep-anxiety-from-coming-back-after-therapy", "question": "How do I keep anxiety from coming back after therapy?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/how-do-i-keep-anxiety-from-coming-back-after-therapy", "markdown": "https://www.asendar.com/gap/q/how-do-i-keep-anxiety-from-coming-back-after-therapy.md", "published": "2026-09-11", "gapNumber": "A synthesis of decades of laboratory and clinical research on fear, extinction, and exposure therapy", "shortAnswer": "Keep practicing what you learned, in many places, after you feel better. The fear you worked through is not erased. Your brain learns a new sense of safety that sits on top of it. That new learning stays strong when you use it often and in different settings, so calm holds when life changes around you.", "keyFinding": "Michelle Craske and her colleagues pulled together decades of research on fear to answer a hard question. Why does a fear that eased in therapy sometimes come back? Their answer reshaped how exposure work is done. When you face a fear and the bad thing does not happen, your brain does not delete the old fear. It learns a new, competing lesson: that you are safe. Both lessons stay in memory. The old fear can resurface when you meet the trigger in a new place, after a long gap, or following a stressful event. The researchers called this an inhibitory learning model, because the new safety lesson works by holding the old fear back rather than removing it. From that model they drew practical ways to make the new learning stronger and more durable. Practice in a way that clearly violates what you expected to go wrong, rather than just waiting for the anxiety to drop. Vary the situations, so the lesson is not tied to one room or one day. Practice across many different settings to keep the calm from staying stuck to a single place. Ease off the safety crutches, the small props and habits people lean on to feel okay, because they can quietly keep the fear alive. And use reminders and cues that help you call up the safe feeling when a new situation catches you off guard. This is a framework built mostly from studies of fear and anxiety, not a single trial with one headline number.", "study": { "authors": "Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A.", "year": "2008", "title": "Optimizing inhibitory learning during exposure therapy", "journal": "Behaviour Research and Therapy", "citation": "Behaviour Research and Therapy, volume 46, issue 1, pages 5 to 27", "doi": "10.1016/j.brat.2007.10.003", "url": "https://doi.org/10.1016/j.brat.2007.10.003" }, "sources": [ "Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5-27. https://doi.org/10.1016/j.brat.2007.10.003" ] }, { "id": "what-does-the-apple-readiness-score-measure-and-what-does-it-miss", "question": "What does the Apple Readiness score measure, and what does it miss?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/what-does-the-apple-readiness-score-measure-and-what-does-it-miss", "markdown": "https://www.asendar.com/gap/q/what-does-the-apple-readiness-score-measure-and-what-does-it-miss.md", "published": "2026-09-09", "gapNumber": "14 composite health scores from 10 wearable makers, including Oura, Garmin, WHOOP, Fitbit, Polar, Samsung, and Withings", "shortAnswer": "Apple's Readiness score is a 0 to 10 number built from your recent activity, training load, vitals, and sleep score. It tells you whether your body is ready to push or needs rest. It does not measure stress, mood, or state of mind. Research shows these body scores often disagree with how a person says they feel.", "keyFinding": "Apple announced Readiness with Apple Watch Series 12 on September 9, 2026. Apple describes it as a single 0 to 10 score with one of four recommendations, Recover, Pace Yourself, Ready, or Go For It, built from recent activity, training load, vitals, and sleep score, to help a person decide how to take on a workday or a training plan. Apple's announcement does not list stress, mood, or mental state as inputs. Readiness joins a crowded field, and that field is what Cailbhe Doherty and colleagues at University College Dublin set out to evaluate. They reviewed 14 composite scores from 10 makers and catalogued what goes into each one. The same inputs showed up almost everywhere: heart rate variability in 86 percent of scores, resting heart rate in 79 percent, physical activity in 71 percent, and sleep duration in 71 percent. Not one maker disclosed its exact formula, and the authors found wide differences in how long a window each score reads and how it weights what it reads. Few makers offered empirical validation or peer-reviewed evidence for the accuracy or clinical relevance of their scores. The authors concluded that composite scores are a promising idea whose scientific validity, transparency, and clinical usefulness remain uncertain.", "study": { "authors": "Doherty, C., Baldwin, M., Lambe, R., Burke, D., and Altini, M.", "year": "2025", "title": "Readiness, recovery, and strain: an evaluation of composite health scores in consumer wearables", "journal": "Translational Exercise Biomedicine", "citation": "Translational Exercise Biomedicine, volume 2, issue 2, pages 128 to 144", "doi": "10.1515/teb-2025-0001", "url": "https://doi.org/10.1515/teb-2025-0001" }, "sources": [ "Doherty, C., Baldwin, M., Lambe, R., Burke, D., & Altini, M. (2025). Readiness, recovery, and strain: an evaluation of composite health scores in consumer wearables. Translational Exercise Biomedicine, 2(2), 128-144. https://doi.org/10.1515/teb-2025-0001", "van der Mee, D. J., Koyuncu, Z., & Lemmers-Jansen, I. L. J. (2025). Are you stressed or just excited? What the Garmin Stress Score can say about your mood. Journal of Affective Disorders Reports, 21, 100974. https://doi.org/10.1016/j.jadr.2025.100974", "Ungaro, C. T., Wolfe, A. S., Isaacs, Z. J., De Chavez, P. J. D., & Freese, E. C. (2026). Disconnection Between Self-Reported Wellbeing and Heart Rate Variability from Wearables. Sensors, 26(4), 1325. https://doi.org/10.3390/s26041325", "Apple Inc. (2026, September 9). Introducing Apple Watch Series 12, with the all-new Health Sensing System. Apple Newsroom. https://www.apple.com/newsroom/2026/09/introducing-apple-watch-series-12-with-the-all-new-health-sensing-system/" ] }, { "id": "are-specific-therapy-goals-better-than-vague-ones", "question": "Are specific therapy goals better than vague ones?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/are-specific-therapy-goals-better-than-vague-ones", "markdown": "https://www.asendar.com/gap/q/are-specific-therapy-goals-better-than-vague-ones.md", "published": "2026-09-08", "gapNumber": "A synthesis of goal-setting research spanning 35 years and more than 400 laboratory and field studies", "shortAnswer": "In general, yes. A specific, challenging goal gives your effort a clear direction, and decades of research find that beats a vague hope like do your best. In therapy, that means naming what you want to be different in plain, concrete terms, rather than aiming to simply feel better.", "keyFinding": "Edwin Locke and Gary Latham spent 35 years on one plain question. Does the kind of goal you set change how you do? In this paper they pulled together more than 400 of their own and others' studies to answer it. The pattern held across that whole body of work. People given a specific and difficult goal did better than people told to do their best, and better than people given no goal at all. Do your best sounds motivating, but it has no clear target, so almost any effort counts as meeting it. They also found that the link between how hard a goal was and how well people did was close to a straight line. Within reason, harder goals led to better results, and the gains only leveled off when a goal ran past a person's ability, or when they stopped believing in it. Locke and Latham described four ways goals do their work. A goal points attention at what matters, it raises effort, it keeps people going for longer, and it pushes them to find better ways to get there. Goals worked best when the person was committed to them, got feedback on how they were doing, and the task was not too complex to plan for.", "study": { "authors": "Locke, E. A., & Latham, G. P.", "year": "2002", "title": "Building a practically useful theory of goal setting and task motivation: A 35-year odyssey", "journal": "American Psychologist", "citation": "American Psychologist, volume 57, pages 705 to 717", "doi": "10.1037/0003-066X.57.9.705", "url": "https://doi.org/10.1037/0003-066X.57.9.705" }, "sources": [ "Locke, E. A., & Latham, G. P. (2002). Building a practically useful theory of goal setting and task motivation: A 35-year odyssey. American Psychologist, 57(9), 705-717. https://doi.org/10.1037/0003-066X.57.9.705" ] }, { "id": "does-understanding-why-i-do-something-actually-help-me-change", "question": "Does understanding why I do something actually help me change?", "pillar": "integration", "page": "https://www.asendar.com/gap/q/does-understanding-why-i-do-something-actually-help-me-change", "markdown": "https://www.asendar.com/gap/q/does-understanding-why-i-do-something-actually-help-me-change.md", "published": "2026-09-08", "gapNumber": "23 independent effect sizes, drawn from 13,849 screened abstracts, across a range of therapy types", "shortAnswer": "Usually it helps. A 2018 meta-analysis pooled 23 studies and found a moderate link between a person's insight, their understanding of their own patterns, and how well therapy went, with a correlation of 0.31. Insight is not the whole story, but it is one of the things that travels with getting better.", "keyFinding": "Simone Jennissen and colleagues at Heidelberg University set out to test something therapists have long assumed but rarely measured: that understanding your own patterns is part of what makes therapy work. They screened 13,849 abstracts and extracted 23 independent effect sizes from the studies that met their criteria. They defined insight carefully, as a person's understanding of the links between past and present experiences, of their typical relationship patterns, and of how interpersonal difficulty, emotional experience, and symptoms connect to each other. That definition matters, because studies had been measuring very different things under the same word. They then ran a random-effects meta-analysis across the pooled studies and found a significant, moderate correlation of r = 0.31 between insight and treatment outcome. They checked whether that result was an artifact of which studies get published, using funnel plot inspection, Egger's regression test, and a trim-and-fill procedure. The finding held up under all three. The authors concluded that insight looks like a relevant mechanism of change, and that it holds across different treatment modalities rather than belonging to one school of therapy.", "study": { "authors": "Jennissen, S., Huber, J., Ehrenthal, J. C., Schauenburg, H., and Dinger, U.", "year": "2018", "title": "Association Between Insight and Outcome of Psychotherapy: Systematic Review and Meta-Analysis", "journal": "American Journal of Psychiatry", "citation": "American Journal of Psychiatry, volume 175, issue 10, pages 961 to 969", "doi": "10.1176/appi.ajp.2018.17080847", "url": "https://doi.org/10.1176/appi.ajp.2018.17080847" }, "sources": [ "Jennissen, S., Huber, J., Ehrenthal, J. C., Schauenburg, H., & Dinger, U. (2018). Association Between Insight and Outcome of Psychotherapy: Systematic Review and Meta-Analysis. American Journal of Psychiatry, 175(10), 961-969. https://doi.org/10.1176/appi.ajp.2018.17080847" ] }, { "id": "does-a-mystical-experience-during-a-session-lead-to-better-outcomes", "question": "Does a mystical experience during a session lead to better outcomes?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/does-a-mystical-experience-during-a-session-lead-to-better-outcomes", "markdown": "https://www.asendar.com/gap/q/does-a-mystical-experience-during-a-session-lead-to-better-outcomes.md", "published": "2026-09-07", "gapNumber": "20 patients with treatment-resistant depression, each with two psilocybin sessions (a lower and a higher one)", "shortAnswer": "Often, yes. In a 2018 study of 20 people with hard to treat depression, those whose session felt more mystical, deep, connected, and boundary dissolving, had lower depression five weeks later. How vivid the visuals were did not predict the benefit. The emotional depth of the experience mattered more than its surface intensity.", "keyFinding": "Leor Roseman and colleagues at Imperial College London studied 20 people with depression that had not responded to earlier treatments. Each person had two psilocybin sessions, a lower one and a higher one. Right after the higher session, the team measured the quality of the experience with a standard questionnaire called the Altered States of Consciousness scale. They focused on two parts of that scale. One was oceanic boundlessness, which captures the mystical side of an experience: a sense of unity, deep positive feeling, and dissolving boundaries. The other was dread of ego dissolution, which captures the hard, anxious, fear of losing yourself side. They then tracked depression with a self-report measure, the Quick Inventory of Depressive Symptoms, and used the five-week score as the main outcome. The quality of the experience predicted how people did. When they modeled these dimensions against symptom change over time, both the mystical dimension and the challenging dimension showed significant relationships with outcome, with main effects at p = 0.002 and p = 0.003. Importantly, the mystical dimension's link to the five-week depression score was specific: it held up compared with the purely sensory and perceptual parts of the experience, such as visions and altered sound, which did not predict benefit (p less than 0.05). The authors concluded that the character of the acute experience, and especially its mystical quality, appears to matter for the longer-term result, not just the fact that a drug was taken.", "study": { "authors": "Roseman, L., Nutt, D. J., and Carhart-Harris, R. L.", "year": "2018", "title": "Quality of Acute Psychedelic Experience Predicts Therapeutic Efficacy of Psilocybin for Treatment-Resistant Depression", "journal": "Frontiers in Pharmacology", "citation": "Frontiers in Pharmacology, volume 8, article 974", "doi": "10.3389/fphar.2017.00974", "url": "https://doi.org/10.3389/fphar.2017.00974" }, "sources": [ "Roseman, L., Nutt, D. J., & Carhart-Harris, R. L. (2018). Quality of Acute Psychedelic Experience Predicts Therapeutic Efficacy of Psilocybin for Treatment-Resistant Depression. Frontiers in Pharmacology, 8, 974. https://doi.org/10.3389/fphar.2017.00974" ] }, { "id": "does-believing-therapy-will-work-make-it-more-likely-to-help", "question": "Does believing therapy will work make it more likely to help?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/does-believing-therapy-will-work-make-it-more-likely-to-help", "markdown": "https://www.asendar.com/gap/q/does-believing-therapy-will-work-make-it-more-likely-to-help.md", "published": "2026-09-06", "gapNumber": "12,722 patients across 81 independent samples", "shortAnswer": "Believing your therapy will help does make a modest difference. Across 81 studies of more than 12,000 people, those who expected treatment to work tended to do a little better than those who did not. The link was small and steady, not a promise. Hope is a real ingredient, not the whole recipe.", "keyFinding": "Michael Constantino and his colleagues pulled together the research on this question in a 2018 meta-analysis in the journal Psychotherapy. They combined 81 separate samples, drawn from 72 studies, covering 12,722 people in real treatment. Every study measured what patients expected from therapy near the start, then measured how they were doing by the end. Pooled together, higher expectations at the start were linked to better outcomes at the end. The size of that link was small: a correlation of 0.18, with a 95 percent confidence interval running from 0.14 to 0.22. In plainer terms, expecting therapy to help nudged the odds in a good direction, but it was one modest factor among many. The pattern held across different diagnoses and different kinds of therapy, which is part of why the authors took it seriously. They were careful to say this is a link, not proof that hope alone drives recovery. People who expect more may also differ in other ways, and the studies cannot fully separate those threads.", "study": { "authors": "Constantino, M. J., Vîslă, A., Coyne, A. E., & Boswell, J. F.", "year": "2018", "title": "A meta-analysis of the association between patients' early treatment outcome expectation and their posttreatment outcomes", "journal": "Psychotherapy", "citation": "Psychotherapy, volume 55, issue 4, pages 473 to 485", "doi": "10.1037/pst0000169", "url": "https://doi.org/10.1037/pst0000169" }, "sources": [ "Constantino, M. J., Vîslă, A., Coyne, A. E., & Boswell, J. F. (2018). A meta-analysis of the association between patients' early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473-485. https://doi.org/10.1037/pst0000169" ] }, { "id": "how-do-i-avoid-sliding-back-after-i-start-to-feel-better", "question": "How do I avoid sliding back after I start to feel better?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/how-do-i-avoid-sliding-back-after-i-start-to-feel-better", "markdown": "https://www.asendar.com/gap/q/how-do-i-avoid-sliding-back-after-i-start-to-feel-better.md", "published": "2026-09-05", "gapNumber": "2,742 participants across 29 randomized trials", "shortAnswer": "The strongest lever is to keep doing the work after you feel better, not to stop once the low lifts. In a review of 2,742 people who had recovered from depression, continuing a structured therapy-based practice cut the risk of sliding back by about a fifth over the next year.", "keyFinding": "Kirsty Clarke and her colleagues gathered 29 randomized trials, 27 head to head comparisons in all, covering 2,742 people who had already recovered from depression. The plain question was whether a talking or skills-based practice, started after someone was well again, could keep them from sliding back. Three approaches were studied: cognitive behavioral therapy, mindfulness-based cognitive therapy, and interpersonal therapy. Pooled together, people who kept up one of these practices after recovery had a 22 percent lower risk of relapse over the next 12 months than people who did not, with a 95 percent confidence interval running from 15 to 29 percent. For cognitive behavioral therapy the benefit was still there at 24 months. For interpersonal therapy it was not, even with sessions continuing, and there was no 24 month data for mindfulness. The authors were careful to note that mindfulness was mostly tested in people who had recovered with the help of medication, so its stand-alone effect is less clear. The honest read is that continuing the work after you feel better lowers the odds of a return, by a meaningful but partial amount.", "study": { "authors": "Clarke, K., Mayo-Wilson, E., Kenny, J., & Pilling, S.", "year": "2015", "title": "Can non-pharmacological interventions prevent relapse in adults who have recovered from depression? A systematic review and meta-analysis of randomised controlled trials", "journal": "Clinical Psychology Review", "citation": "Clinical Psychology Review, volume 39, pages 58 to 70", "doi": "10.1016/j.cpr.2015.04.002", "url": "https://doi.org/10.1016/j.cpr.2015.04.002" }, "sources": [ "Clarke, K., Mayo-Wilson, E., Kenny, J., & Pilling, S. (2015). Can non-pharmacological interventions prevent relapse in adults who have recovered from depression? A systematic review and meta-analysis of randomised controlled trials. Clinical Psychology Review, 39, 58-70. https://doi.org/10.1016/j.cpr.2015.04.002" ] }, { "id": "how-do-i-hold-on-to-what-i-learned-between-sessions", "question": "How do I hold on to what I learned between sessions?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/how-do-i-hold-on-to-what-i-learned-between-sessions", "markdown": "https://www.asendar.com/gap/q/how-do-i-hold-on-to-what-i-learned-between-sessions.md", "published": "2026-09-03", "gapNumber": "159 effect sizes from published testing-effect experiments", "shortAnswer": "To hold on to what you learned between sessions, do not just look over your notes. Bring what you learned to mind on your own, out loud or on paper, in short moments across the week. In memory research, that kind of active retrieval is what makes learning last.", "keyFinding": "Christopher Rowland pulled together 159 comparisons from published experiments on the testing effect, the finding that trying to recall something sticks better than reading it again. Across those studies, being tested on what you had learned beat re-reading it, with a pooled effect size of about 0.50 in Hedges's g, and a 95 percent confidence interval from 0.42 to 0.58. That number is a moderate effect, which means a clear and useful difference, not a tiny one and not a miracle. The pattern held up across a wide range of study designs. The effect was larger when the material was more complex, when the retrieval took real effort, and when the person got feedback on how they did. Rowland's read was steady. On average, calling something back to mind is a stronger way to keep it than reading it again.", "study": { "authors": "Rowland, C. A.", "year": "2014", "title": "The effect of testing versus restudy on retention: A meta-analytic review of the testing effect", "journal": "Psychological Bulletin", "citation": "Psychological Bulletin, volume 140, pages 1432 to 1463", "doi": "10.1037/a0037559", "url": "https://doi.org/10.1037/a0037559" }, "sources": [ "Rowland, C. A. (2014). The effect of testing versus restudy on retention: A meta-analytic review of the testing effect. Psychological Bulletin, 140(6), 1432-1463. https://doi.org/10.1037/a0037559" ] }, { "id": "why-do-insights-from-a-session-fade-so-fast", "question": "Why do insights from a session fade so fast?", "pillar": "integration", "page": "https://www.asendar.com/gap/q/why-do-insights-from-a-session-fade-so-fast", "markdown": "https://www.asendar.com/gap/q/why-do-insights-from-a-session-fade-so-fast.md", "published": "2026-09-02", "gapNumber": "one dedicated participant who completed about 70 hours of learning and relearning", "shortAnswer": "Insights fade fast because that is how ordinary memory works. Research that repeated the classic forgetting curve found people lose most of what they learn within the first day, with the steepest drop in the first hours. An insight is a memory too, so it blurs quickly unless you capture it and come back to it.", "keyFinding": "Jaap Murre and Joeri Dros set out to test whether Hermann Ebbinghaus's famous 1885 forgetting curve would hold up when it was repeated with care. They used the same method of savings, which measures how much faster a list is to relearn than it was the first time. One dedicated participant spent about 70 hours learning lists of syllables and then relearning them after set delays: 20 minutes, 1 hour, 9 hours, 1 day, 2 days, and 31 days. The pattern matched the original closely. Retention dropped sharply at first and then leveled off. Most of the loss happened well inside the first day, and the steepest fall came between one hour and nine hours. By 24 hours only about 27 percent was still held, and by a month it sat near 20 percent. One detail stood out. The curve was not perfectly smooth. Retention ticked slightly upward around the 24 hour mark, which the authors linked to a night of sleep and the memory consolidation that happens during it.", "study": { "authors": "Murre, J. M. J., and Dros, J.", "year": "2015", "title": "Replication and Analysis of Ebbinghaus' Forgetting Curve", "journal": "PLOS ONE", "citation": "PLOS ONE, volume 10, issue 7, article e0120644", "doi": "10.1371/journal.pone.0120644", "url": "https://doi.org/10.1371/journal.pone.0120644" }, "sources": [ "Murre, J. M. J., & Dros, J. (2015). Replication and Analysis of Ebbinghaus' Forgetting Curve. PLOS ONE, 10(7), e0120644. https://doi.org/10.1371/journal.pone.0120644" ] }, { "id": "what-does-it-mean-to-surrender-during-a-session", "question": "What does it mean to surrender during a session?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/what-does-it-mean-to-surrender-during-a-session", "markdown": "https://www.asendar.com/gap/q/what-does-it-mean-to-surrender-during-a-session.md", "published": "2026-09-01", "gapNumber": "183 people who had taken psilocybin on their own in the past year", "shortAnswer": "Surrender means letting go of the urge to control the experience and allowing it to unfold. In plant medicine research, the state of surrender a person carried into a session was the strongest predictor of a deep, mystical-type experience, while a mind stuck on worry was the strongest predictor of a harder, more distressing one.", "keyFinding": "Suzanne Russ and colleagues, including Robin Carhart-Harris, gathered detailed reports from 183 people who had taken psilocybin on their own in the past year. It was a retrospective survey, so people described sessions that had already happened. The team built a statistical model to see what best explained how each session went. Two states of mind at the start stood out. A state of surrender, meaning a willingness to let go and stop fighting the experience, was the strongest predictor of a mystical-type experience. A state of preoccupation, meaning a mind stuck on worries and unable to settle, was the strongest predictor of a challenging or distressing experience. The model was strong. It accounted for about 66 percent of the differences between people in their mystical-experience scores, and about 56 percent of the differences on a measure of dread. A trait called absorption, the tendency to get deeply drawn into inner experience, was the next strongest factor in both. The researchers also found that having a mystical-type experience during the session was linked to lasting positive change afterward.", "study": { "authors": "Russ, S. L., Carhart-Harris, R. L., Maruyama, G., and Elliott, M. S.", "year": "2019", "title": "Replication and extension of a model predicting response to psilocybin", "journal": "Psychopharmacology", "citation": "Psychopharmacology, volume 236, issue 11, pages 3221 to 3230", "doi": "10.1007/s00213-019-05279-z", "url": "https://doi.org/10.1007/s00213-019-05279-z" }, "sources": [ "Russ, S. L., Carhart-Harris, R. L., Maruyama, G., & Elliott, M. S. (2019). Replication and extension of a model predicting response to psilocybin. Psychopharmacology, 236(11), 3221-3230. https://doi.org/10.1007/s00213-019-05279-z" ] }, { "id": "can-holding-on-to-the-wrong-intention-slow-your-progress", "question": "Can holding on to the wrong intention slow your progress?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/can-holding-on-to-the-wrong-intention-slow-your-progress", "markdown": "https://www.asendar.com/gap/q/can-holding-on-to-the-wrong-intention-slow-your-progress.md", "published": "2026-08-31", "gapNumber": "31 samples, 421 effect sizes", "shortAnswer": "Maybe. Research on goal adjustment suggests that clinging to a goal you can no longer reach is linked to more distress, while being able to let it go and aim at a new one is linked to better well-being. The wrong intention is one you have outgrown but keep holding anyway.", "keyFinding": "Meaghan Barlow, Carsten Wrosch, and Jennifer McGrath ran a meta-analysis published in the Journal of Personality in 2020. They pooled 31 separate samples and 421 effect sizes and asked one plain question. How does a person's ability to adjust their goals relate to their quality of life? They looked at two skills. Goal disengagement is being able to let go of a goal you can no longer reach. Goal reengagement is being able to put your energy into a new goal instead. Both were linked to better quality of life. Disengagement had a small link, r = 0.08. Reengagement had a larger one, r = 0.19. The pattern underneath is the interesting part. Being able to let go was tied most to carrying fewer negative feelings, like distress, with a correlation of r = -0.12. It barely moved the positive side of well-being, r = 0.02, which was not statistically meaningful. Reengagement, aiming at something new, was tied to both more positive feeling, r = 0.24, and fewer negative ones, r = -0.17. So letting go of the wrong goal is linked to less suffering, and choosing a new direction is linked to actually feeling better.", "study": { "authors": "Barlow, M. A., Wrosch, C., & McGrath, J. J.", "year": "2020", "title": "Goal adjustment capacities and quality of life: A meta-analytic review", "journal": "Journal of Personality", "citation": "Journal of Personality, volume 88, issue 2, pages 307 to 323", "doi": "10.1111/jopy.12492", "url": "https://doi.org/10.1111/jopy.12492" }, "sources": [ "Barlow, M. A., Wrosch, C., & McGrath, J. J. (2020). Goal adjustment capacities and quality of life: A meta-analytic review. Journal of Personality, 88(2), 307-323. https://doi.org/10.1111/jopy.12492" ] }, { "id": "what-does-a-mental-maintenance-routine-look-like", "question": "What does a mental maintenance routine look like?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/what-does-a-mental-maintenance-routine-look-like", "markdown": "https://www.asendar.com/gap/q/what-does-a-mental-maintenance-routine-look-like.md", "published": "2026-08-30", "gapNumber": "1,258 adults with recurrent depression, across nine randomized trials", "shortAnswer": "A mental maintenance routine is a small, regular practice you keep after the intensive work ends. In one large review, people who kept up a structured mindfulness routine were less likely to slip back into depression. It does not need to be long. It needs to be steady and repeated.", "keyFinding": "Willem Kuyken and his colleagues pooled the individual data of 1,258 adults who had recovered from repeated bouts of depression, drawn from nine randomized trials run in the UK, Belgium, Canada, the Netherlands, and Switzerland. Everyone in the analysis had a history of depression coming back, so the question was plain: can a regular mindfulness routine lower the odds of it returning? The routine studied was mindfulness-based cognitive therapy, a structured practice of noticing thoughts and feelings without getting swept up in them. Over 60 weeks of follow-up, 38 percent of the people who did the mindfulness routine had a relapse, compared with 49 percent of those who did not. That worked out to about a 31 percent lower risk of relapse for the routine group. The routine also came out slightly ahead of staying on medication alone, with about a 23 percent lower risk of relapse than continued antidepressants without it. The benefit was largest in the people who had started with the heaviest symptoms. The plain read is that a steady, structured mental practice, kept up after the main treatment, helped a meaningful share of people hold their ground.", "study": { "authors": "Kuyken, W., Warren, F. C., Taylor, R. S., Whalley, B., Crane, C., Bondolfi, G., Dalgleish, T., et al.", "year": "2016", "title": "Efficacy of Mindfulness-Based Cognitive Therapy in Prevention of Depressive Relapse: An Individual Patient Data Meta-analysis From Randomized Trials", "journal": "JAMA Psychiatry", "citation": "JAMA Psychiatry, volume 73, pages 565 to 574", "doi": "", "url": "" }, "sources": [ "Kuyken, W., Warren, F. C., Taylor, R. S., Whalley, B., Crane, C., Bondolfi, G., Dalgleish, T., et al. (2016). Efficacy of Mindfulness-Based Cognitive Therapy in Prevention of Depressive Relapse: An Individual Patient Data Meta-analysis From Randomized Trials. JAMA Psychiatry, 73(6), 565-574. https://doi.org/10.1001/jamapsychiatry.2016.0076" ] }, { "id": "why-does-progress-feel-slower-between-sessions", "question": "Why does progress feel slower between sessions?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/why-does-progress-feel-slower-between-sessions", "markdown": "https://www.asendar.com/gap/q/why-does-progress-feel-slower-between-sessions.md", "published": "2026-08-29", "gapNumber": "1,104 people across 16 treatment studies", "shortAnswer": "Often because change in therapy is not smooth. It tends to come in jumps, not a steady climb. A large review found that a big share of a person's total improvement can arrive in a single stretch between two sessions. So the flat weeks can feel like nothing, even when the overall path is upward.", "keyFinding": "Idan Aderka, Angela Nickerson, Hans Jakob Bøe, and Stefan Hofmann pooled 16 studies covering 1,104 people who were in psychological treatment for depression or an anxiety disorder. They focused on a pattern called a sudden gain, which is a large drop in symptoms across a single gap between two sessions. In the original work that named the pattern, these jumps averaged about a quarter of a person's symptoms and made up roughly half of their total improvement, and this review set out to test how much that held across many studies at once. People who had a sudden gain ended treatment in a better place than people who did not, with a moderate effect size of 0.62, and they were still doing better at follow-up, with an effect size of 0.56. The plain read of the numbers is that a lot of real change does not trickle in evenly. It lands in bursts, and long flat stretches sit in between.", "study": { "authors": "Aderka, I. M., Nickerson, A., Bøe, H. J., and Hofmann, S. G.", "year": "2012", "title": "Sudden gains during psychological treatments of anxiety and depression: A meta-analysis", "journal": "Journal of Consulting and Clinical Psychology", "citation": "Journal of Consulting and Clinical Psychology, volume 80, pages 93 to 101", "doi": "10.1037/a0026455", "url": "https://doi.org/10.1037/a0026455" }, "sources": [ "Aderka, I. M., Nickerson, A., Bøe, H. J., & Hofmann, S. G. (2012). Sudden gains during psychological treatments of anxiety and depression: A meta-analysis. Journal of Consulting and Clinical Psychology, 80(1), 93-101. https://doi.org/10.1037/a0026455" ] }, { "id": "does-talking-about-a-session-help-you-process-it", "question": "Does talking about a session help you process it?", "pillar": "integration", "page": "https://www.asendar.com/gap/q/does-talking-about-a-session-help-you-process-it", "markdown": "https://www.asendar.com/gap/q/does-talking-about-a-session-help-you-process-it.md", "published": "2026-08-28", "gapNumber": "88 adults with a strong fear of spiders", "shortAnswer": "Yes, and the way you talk matters. Naming what you feel out loud, in plain words, helps your body settle and helps you face hard things. In one study, people who put their fear into words during exposure showed a calmer stress response a week later than people who distracted themselves.", "keyFinding": "Katharina Kircanski, Matthew Lieberman, and Michelle Craske worked with 88 adults who had a strong fear of spiders. Everyone did the same thing. They slowly approached a live tarantula in an open container, one step at a time. The researchers split the group four ways, changing only what people did with their feelings while they faced the spider. One group named the fear out loud in plain words, something like \"I feel anxious and scared of this spider.\" A second group tried to reframe the fear, a third distracted themselves, and a fourth just did the exposure with no instruction. A week later, everyone faced a different spider in a different room. The group that had named the fear out loud showed the lowest skin conductance, a standard body measure of stress arousal, compared with the other three groups. Within that group, the people who used more fear and anxiety words during the first session showed the biggest drop in that stress response and took more steps toward the spider. Putting the feeling into words, not away, tracked with a calmer body.", "study": { "authors": "Kircanski, K., Lieberman, M. D., and Craske, M. G.", "year": "2012", "title": "Feelings Into Words: Contributions of Language to Exposure Therapy", "journal": "Psychological Science", "citation": "Psychological Science, volume 23, pages 1086 to 1091", "doi": "10.1177/0956797612443830", "url": "https://doi.org/10.1177/0956797612443830" }, "sources": [ "Kircanski, K., Lieberman, M. D., & Craske, M. G. (2012). Feelings Into Words: Contributions of Language to Exposure Therapy. Psychological Science, 23(10), 1086-1091. https://doi.org/10.1177/0956797612443830" ] }, { "id": "why-do-some-sessions-feel-more-intense-than-others", "question": "Why do some sessions feel more intense than others?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/why-do-some-sessions-feel-more-intense-than-others", "markdown": "https://www.asendar.com/gap/q/why-do-some-sessions-feel-more-intense-than-others.md", "published": "2026-08-27", "gapNumber": "409 psilocybin sessions given to 261 healthy volunteers, pooled from 23 controlled studies", "shortAnswer": "Sessions differ because more than the medicine shapes them. In a large analysis of psilocybin sessions, how intense and how pleasant an experience felt depended on the person's mood going in, a trait called absorption, and the setting around them. The same medicine can land very differently on different days.", "keyFinding": "Erich Studerus and colleagues at the University of Zurich pooled the records from 23 controlled experimental studies run in the same lab. That gave them 409 psilocybin sessions across 261 healthy volunteers, one of the largest collections of its kind. They tested 24 possible predictors of how each session went, from age and sex to personality traits, recent mental state, and the setting of the session. The strength of the medicine itself was the single biggest factor, as you would expect. But it was not the only one. Several non-drug factors clearly shaped the experience too. People who scored high on a trait called absorption, meaning a tendency to get deeply drawn into imagery, music, and inner experience, and people who felt emotionally alive and active right before the session, and who had been through few psychological struggles in the prior weeks, were the most likely to have pleasant and mystical-type experiences. On the other side, high emotional excitability, younger age, and a more clinical, high-stimulation setting were the factors most tied to anxious or unpleasant reactions. The authors concluded that non-pharmacological variables play an important role in how a session unfolds.", "study": { "authors": "Studerus, E., Gamma, A., Kometer, M., and Vollenweider, F. X.", "year": "2012", "title": "Prediction of psilocybin response in healthy volunteers", "journal": "PLoS ONE", "citation": "PLoS ONE, volume 7, issue 2, article e30800", "doi": "", "url": "" }, "sources": [ "Studerus, E., Gamma, A., Kometer, M., & Vollenweider, F. X. (2012). Prediction of psilocybin response in healthy volunteers. PLoS ONE, 7(2), e30800. https://doi.org/10.1371/journal.pone.0030800" ] }, { "id": "why-do-therapists-ask-you-to-set-an-intention", "question": "Why do therapists ask you to set an intention?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/why-do-therapists-ask-you-to-set-an-intention", "markdown": "https://www.asendar.com/gap/q/why-do-therapists-ask-you-to-set-an-intention.md", "published": "2026-08-26", "gapNumber": "295 studies, more than 30,000 people in therapy", "shortAnswer": "Therapists ask because naming what you want to work on is part of building the therapeutic alliance, the shared, working bond between you and your therapist. A 2018 review of 295 studies and more than 30,000 people found that the strength of that alliance was one of the steadiest markers of how therapy turned out.", "keyFinding": "Christoph Flückiger and his colleagues pooled 295 separate studies, published between 1978 and 2017, covering more than 30,000 people in therapy. They asked one plain question. How strongly does the alliance between a client and their therapist relate to how therapy turns out? The alliance is the working bond between the two of you, and researchers describe it as having three parts: agreement on the goals of the work, agreement on how you will get there, and the personal bond between you. Setting an intention is the first of those three, the goals part, made concrete. Across all 295 studies, a stronger alliance went with better outcomes. The size of that link was r = 0.278, with a 95 percent confidence interval of 0.256 to 0.299. That is a modest but very steady relationship, and it held across different kinds of therapy, different problems, and different ways of measuring the alliance. It is one of the most repeated findings in all of psychotherapy research. What the review cannot tell you is which way the arrow points. A strong alliance may help therapy work, or therapy that is working may build a strong alliance. Most likely both are true at once.", "study": { "authors": "Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O.", "year": "2018", "title": "The alliance in adult psychotherapy: A meta-analytic synthesis", "journal": "Psychotherapy", "citation": "Psychotherapy, volume 55, issue 4, pages 316 to 340", "doi": "10.1037/pst0000172", "url": "https://doi.org/10.1037/pst0000172" }, "sources": [ "Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316-340. https://doi.org/10.1037/pst0000172" ] }, { "id": "how-often-should-i-revisit-my-therapy-goals", "question": "How often should I revisit my therapy goals?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/how-often-should-i-revisit-my-therapy-goals", "markdown": "https://www.asendar.com/gap/q/how-often-should-i-revisit-my-therapy-goals.md", "published": "2026-08-25", "gapNumber": "58 studies, 110 effect sizes, 21,699 people", "shortAnswer": "There is no magic number. But checking your progress on a steady rhythm helps. A 2021 review of 58 studies found that regular progress feedback modestly improved therapy outcomes and cut dropout by about a fifth. The benefit was largest for people whose progress had drifted off track.", "keyFinding": "Kim de Jong and her colleagues gathered 58 studies, drawn from 49 randomized trials and 9 real-world clinics, covering 21,699 people in therapy. They asked a plain question. Does it help when a therapist regularly tracks how a client is doing and feeds that progress back into the work? The answer was a small but steady yes. On symptom improvement, progress feedback beat usual care by a modest margin, an effect the researchers measured at d = 0.15. It also lowered the number of people who dropped out of therapy, with the odds of dropping out about a fifth lower when feedback was used. The benefit was clearest for one group in particular. When someone's progress had quietly drifted off track, regular feedback helped more, at d = 0.17. Two things the review did not find are worth naming. Regular feedback did not shorten how long treatment lasted, and it did not lower the share of people who got worse. The authors are careful to call feedback a small add-on, a light tool laid over the real work of therapy, not a treatment on its own.", "study": { "authors": "de Jong, K., Conijn, J. M., Gallagher, R. A. V., Reshetnikova, A. S., Heij, M., & Lutz, M. C.", "year": "2021", "title": "Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: A multilevel meta-analysis", "journal": "Clinical Psychology Review", "citation": "Clinical Psychology Review, volume 85, article 102002", "doi": "10.1016/j.cpr.2021.102002", "url": "https://doi.org/10.1016/j.cpr.2021.102002" }, "sources": [ "de Jong, K., Conijn, J. M., Gallagher, R. A. V., Reshetnikova, A. S., Heij, M., & Lutz, M. C. (2021). Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: A multilevel meta-analysis. Clinical Psychology Review, 85, 102002. https://doi.org/10.1016/j.cpr.2021.102002" ] }, { "id": "is-it-normal-to-feel-flat-between-sessions", "question": "Is it normal to feel flat between sessions?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/is-it-normal-to-feel-flat-between-sessions", "markdown": "https://www.asendar.com/gap/q/is-it-normal-to-feel-flat-between-sessions.md", "published": "2026-08-24", "gapNumber": "752 adults with depression who were taking a prescribed antidepressant, surveyed online in Brazil, Canada, and Spain in 2021", "shortAnswer": "Yes, feeling flat, numb, or emotionally muted is common, and it does not mean something is wrong with you. In a survey of 752 people with depression, emotional blunting was widespread, and most people in an active phase of depression described it as severe. For many, the flatness eases over time.", "keyFinding": "Michael Cronquist Christensen and his colleagues surveyed 752 adults who were living with depression and taking a prescribed antidepressant, across Brazil, Canada, and Spain, in 2021. Everyone in the survey reported some emotional blunting, a sense of feeling flat, numb, or emotionally muted. The team measured it with the Oxford Depression Questionnaire, a standard scale for this experience, where higher scores mean more blunting. What stood out was not just that blunting was there, but how heavy it often felt. Just under half of the group, about 44 percent, rated their emotional blunting as most severe. Among people in an active phase of depression, that share rose to roughly 7 in 10. Among people whose depression was in remission, it was closer to 1 in 4. More than half of the group connected the flatness to their depression itself, and many also connected it to their treatment. The authors read this as evidence that emotional blunting is a frequent and often serious part of living with depression, one that deserves attention rather than silence.", "study": { "authors": "Christensen, M. C., Ren, H., & Fagiolini, A.", "year": "2022", "title": "Emotional blunting in patients with depression. Part I: clinical characteristics", "journal": "Annals of General Psychiatry", "citation": "Annals of General Psychiatry, volume 21, article 10", "doi": "10.1186/s12991-022-00387-1", "url": "https://doi.org/10.1186/s12991-022-00387-1" }, "sources": [ "Christensen, M. C., Ren, H., & Fagiolini, A. (2022). Emotional blunting in patients with depression. Part I: clinical characteristics. Annals of General Psychiatry, 21, 10. https://doi.org/10.1186/s12991-022-00387-1" ] }, { "id": "what-should-i-do-the-day-after-an-intense-session", "question": "What should I do the day after an intense session?", "pillar": "integration", "page": "https://www.asendar.com/gap/q/what-should-i-do-the-day-after-an-intense-session", "markdown": "https://www.asendar.com/gap/q/what-should-i-do-the-day-after-an-intense-session.md", "published": "2026-08-23", "gapNumber": "158 studies pooled, 450 separate results, 13,101 people in total", "shortAnswer": "Keep it gentle and small. The day after often feels flat, and one of the best-supported ways to lift a flat mood is a short, easy walk. A large review of exercise studies found that light movement reliably raised energy and mood, and the boost was biggest in people who started out low. Rest too. Go slow.", "keyFinding": "Jennifer Reed and Deniz Ones combined 158 studies run between 1979 and 2005, covering 450 separate results and 13,101 people. They measured one thing: positive activated affect, the bundle of feelings like energy, alertness, and enthusiasm. Across all of that data, a single bout of aerobic exercise raised positive activated affect, with an average effect size of 0.47, which is a solid, real effect. Two details matter for a hard day. The lift was largest for low intensity movement, not hard workouts, and for sessions of roughly 35 minutes or less. And it was nearly doubled in the people who started out lower than average. In other words, the people who felt the flattest going in tended to gain the most.", "study": { "authors": "Reed, J., and Ones, D. S.", "year": "2006", "title": "The effect of acute aerobic exercise on positive activated affect: A meta-analysis", "journal": "Psychology of Sport and Exercise", "citation": "Psychology of Sport and Exercise, volume 7, pages 477 to 514", "doi": "10.1016/j.psychsport.2005.11.003", "url": "https://doi.org/10.1016/j.psychsport.2005.11.003" }, "sources": [ "Reed, J., & Ones, D. S. (2006). The effect of acute aerobic exercise on positive activated affect: A meta-analysis. Psychology of Sport and Exercise, 7, 477-514. https://doi.org/10.1016/j.psychsport.2005.11.003" ] }, { "id": "how-does-music-shape-what-happens-in-a-session", "question": "How does music shape what happens in a session?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/how-does-music-shape-what-happens-in-a-session", "markdown": "https://www.asendar.com/gap/q/how-does-music-shape-what-happens-in-a-session.md", "published": "2026-08-20", "gapNumber": "19 patients in psilocybin therapy for treatment-resistant depression", "shortAnswer": "Music is not background. In sessions, it shapes what you feel and see, guides where your attention goes, and can steady you when things get intense. In one study of psilocybin therapy, how patients related to the music predicted their mood a week later, more than the drug itself did.", "keyFinding": "Mendel Kaelen and colleagues at Imperial College London looked at a part of plant medicine therapy that usually goes unexamined: the music. Nineteen patients being treated with psilocybin for treatment-resistant depression sat through sessions with a curated playlist, then spoke about the music afterward in semi-structured interviews. The team read those interviews closely to find the common threads. The themes that came up most often were that the music intensified emotions and stirred vivid mental imagery. Patients also described the music as a kind of guide, something that gave them a sense of grounding and carried them from one inner place to the next, almost like a presence in the room. Then came the striking part. When the researchers compared how patients related to the music with how intense the drug felt, it was the experience of the music, not the intensity of the drug, that predicted how much their depression had eased one week later. The authors called music a hidden therapist and argued it plays a central, active role in this kind of therapy rather than sitting quietly in the background.", "study": { "authors": "Kaelen, M., Giribaldi, B., Raine, J., and colleagues", "year": "2018", "title": "The hidden therapist: evidence for a central role of music in psychedelic therapy", "journal": "Psychopharmacology", "citation": "Psychopharmacology, volume 235, issue 2, pages 505 to 519", "doi": "10.1007/s00213-017-4820-5", "url": "https://doi.org/10.1007/s00213-017-4820-5" }, "sources": [ "Kaelen, M., Giribaldi, B., Raine, J., Evans, L., Timmermann, C., Rodriguez, N., Roseman, L., Feilding, A., Nutt, D., & Carhart-Harris, R. (2018). The hidden therapist: evidence for a central role of music in psychedelic therapy. Psychopharmacology, 235(2), 505-519. https://doi.org/10.1007/s00213-017-4820-5" ] }, { "id": "does-writing-down-your-goals-before-therapy-help", "question": "Does writing down your goals before therapy help?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/does-writing-down-your-goals-before-therapy-help", "markdown": "https://www.asendar.com/gap/q/does-writing-down-your-goals-before-therapy-help.md", "published": "2026-08-16", "gapNumber": "141 studies, 384 effect sizes, 16,523 participants", "shortAnswer": "Writing a goal down is a simple way to make it specific, and specific goals are what the research supports. A 2017 review of 141 studies found that setting a clear goal makes behavior change more likely. The effect was stronger when the goal was challenging and when it was shared openly.", "keyFinding": "Tracy Epton and her colleagues gathered 141 studies that tested one thing on its own. Does setting a goal actually change what people do? Across 384 separate comparisons and 16,523 people, the answer was yes. Setting a goal produced a small but real effect on behavior, measured at d = 0.34. Small does not mean trivial here. It means a steady push that showed up again and again across many different behaviors, most of them everyday health habits like eating, moving more, and cutting back on smoking. The team also tested what made goals work better. Three things stood out. Goals helped most when they were difficult rather than easy, when they were set in public rather than kept private, and when they were shared as a group goal. There was weaker evidence that goals worked better when another person kept an eye on progress, and when the goal was set face to face. One honest note. This was a test of setting a goal, not of writing one down. So the writing is best seen as one plain way to make a goal specific and open.", "study": { "authors": "Epton, T., Currie, S., & Armitage, C. J.", "year": "2017", "title": "Unique effects of setting goals on behavior change: Systematic review and meta-analysis", "journal": "Journal of Consulting and Clinical Psychology", "citation": "Journal of Consulting and Clinical Psychology, volume 85, pages 1182 to 1198", "doi": "10.1037/ccp0000260", "url": "https://doi.org/10.1037/ccp0000260" }, "sources": [ "Epton, T., Currie, S., & Armitage, C. J. (2017). Unique effects of setting goals on behavior change: Systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 85(12), 1182-1198. https://doi.org/10.1037/ccp0000260" ] }, { "id": "does-a-daily-check-in-habit-help-mental-health", "question": "Does a daily check-in habit help mental health?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/does-a-daily-check-in-habit-help-mental-health", "markdown": "https://www.asendar.com/gap/q/does-a-daily-check-in-habit-help-mental-health.md", "published": "2026-08-15", "gapNumber": "138 studies, 19,951 participants", "shortAnswer": "Checking in on yourself regularly is one of the more reliable ways to actually reach a goal. A large 2016 review of 138 studies found that people who monitored their own progress more often were more likely to follow through. Recording it, or sharing it, made the effect stronger.", "keyFinding": "Benjamin Harkin and his colleagues pulled together 138 separate studies, covering 19,951 people, to test one plain question. Does keeping an eye on your own progress help you get where you want to go? The answer was a clear yes. When people were prompted to check in on their progress more often, they did so far more, a large effect the researchers measured at d+ = 1.98. And that extra checking in fed straight into results. People who monitored their progress were more likely to reach their goal, with a moderate and steady effect of d+ = 0.40. The link ran through the checking itself. More monitoring led to more follow through. Two things made it work even better. Writing the progress down, and sharing it with other people, both strengthened the effect. Most of the goals in these studies were personal health goals, like changing eating habits, moving more, or cutting back on smoking.", "study": { "authors": "Harkin, B., Webb, T. L., Chang, B. P. I., Prestwich, A., Conner, M., Kellar, I., Benn, Y., & Sheeran, P.", "year": "2016", "title": "Does monitoring goal progress promote goal attainment? A meta-analysis of the experimental evidence", "journal": "Psychological Bulletin", "citation": "Psychological Bulletin, volume 142, pages 198 to 229", "doi": "10.1037/bul0000025", "url": "https://doi.org/10.1037/bul0000025" }, "sources": [ "Harkin, B., Webb, T. L., Chang, B. P. I., Prestwich, A., Conner, M., Kellar, I., Benn, Y., & Sheeran, P. (2016). Does monitoring goal progress promote goal attainment? A meta-analysis of the experimental evidence. Psychological Bulletin, 142(2), 198-229. https://doi.org/10.1037/bul0000025" ] }, { "id": "how-long-does-the-afterglow-last-after-a-session", "question": "How long does the afterglow last after a session?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/how-long-does-the-afterglow-last-after-a-session", "markdown": "https://www.asendar.com/gap/q/how-long-does-the-afterglow-last-after-a-session.md", "published": "2026-08-13", "gapNumber": "48 studies pooling 1,774 participants, spanning research from 1950 to 2021", "shortAnswer": "There is no exact clock. Researchers call this the afterglow, and they study it as a subacute window that runs from about a day to a month after a session. In a 2023 review of 48 studies, lifts in mood and connection were common in that window, then faded. Give it weeks, not hours.", "keyFinding": "A team led by Ricarda Evens at Freie Universitat Berlin gathered 48 studies published between 1950 and 2021, covering 1,774 people who took a classic plant medicine such as psilocybin, LSD, or ayahuasca. They focused on the subacute window, the stretch from about one day to one month after a session, once the acute effects had worn off. Across the studies, this window often held measurable lifts in mood, wellbeing, mindfulness, and a sense of connection to other people, along with drops in some symptoms. These changes were transient, meaning they eased over the following days and weeks rather than lasting on their own. The review also logged subacute downsides for some people, including headaches, disturbed sleep, and in a few cases more psychological distress. The authors are clear that the older, mixed, and often uncontrolled studies show a pattern, not a precise timeline.", "study": { "authors": "Evens, R., Schmidt, M. E. S., Majić, T., and Schmidt, T. T.", "year": "2023", "title": "The psychedelic afterglow phenomenon: a systematic review of subacute effects of classic serotonergic psychedelics", "journal": "Therapeutic Advances in Psychopharmacology", "citation": "Therapeutic Advances in Psychopharmacology, volume 13", "doi": "10.1177/20451253231172254", "url": "https://doi.org/10.1177/20451253231172254" }, "sources": [ "Evens, R., Schmidt, M. E. S., Majić, T., & Schmidt, T. T. (2023). The psychedelic afterglow phenomenon: a systematic review of subacute effects of classic serotonergic psychedelics. Therapeutic Advances in Psychopharmacology, 13. https://doi.org/10.1177/20451253231172254" ] }, { "id": "how-long-does-it-take-to-integrate-a-big-session", "question": "How long does it take to integrate a big session?", "pillar": "integration", "page": "https://www.asendar.com/gap/q/how-long-does-it-take-to-integrate-a-big-session", "markdown": "https://www.asendar.com/gap/q/how-long-does-it-take-to-integrate-a-big-session.md", "published": "2026-08-10", "gapNumber": "51 healthy adults, assessed before and after psilocybin sessions", "shortAnswer": "There is no fixed clock. Integration unfolds over weeks and months, not hours. In one study of a single psilocybin session, a meaningful shift showed up at one to two months and was still present more than a year later. So give a big session time. The work is slow by design, and that is normal.", "keyFinding": "Katherine MacLean, Matthew Johnson, and Roland Griffiths studied 51 healthy adults who took part in psilocybin sessions in a controlled research setting. They measured personality with a standard questionnaire, the NEO-PI-R, before the sessions, then one to two months after, and once more over a year later. Across the group, one trait moved: openness, which covers imagination, curiosity, and receptivity to new experience. Openness rose after the session and stayed higher at the 14-month follow-up. The lift was concentrated in the roughly 30 people who reported a complete mystical-type experience during their session. People who did not have that kind of experience showed no lasting change. A shift in adult personality that holds for more than a year is unusual, which is why the finding drew so much attention.", "study": { "authors": "MacLean, K. A., Johnson, M. W., and Griffiths, R. R.", "year": "2011", "title": "Mystical experiences occasioned by the hallucinogen psilocybin lead to increases in the personality domain of openness", "journal": "Journal of Psychopharmacology", "citation": "Journal of Psychopharmacology, volume 25, pages 1453 to 1461", "doi": "10.1177/0269881111420188", "url": "https://doi.org/10.1177/0269881111420188" }, "sources": [ "MacLean, K. A., Johnson, M. W., & Griffiths, R. R. (2011). Mystical experiences occasioned by the hallucinogen psilocybin lead to increases in the personality domain of openness. Journal of Psychopharmacology, 25(11), 1453-1461. https://doi.org/10.1177/0269881111420188" ] }, { "id": "what-does-it-feel-like-to-dissociate-during-a-session", "question": "What does it feel like to dissociate during a session?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/what-does-it-feel-like-to-dissociate-during-a-session", "markdown": "https://www.asendar.com/gap/q/what-does-it-feel-like-to-dissociate-during-a-session.md", "published": "2026-08-09", "gapNumber": "a clinically diverse group of more than 100 people, including trauma survivors, people with other psychiatric conditions, and healthy volunteers", "shortAnswer": "Dissociation during a session often feels like detachment. You may feel disconnected from your body, as if you are watching yourself from a distance. The room can look unreal or dreamlike. Time may speed up or stall. Researchers built a validated scale that captures these exact sensations, so the experience is known and measurable.", "keyFinding": "In 1998, J. Douglas Bremner, John Krystal, Frank Putnam, and their colleagues set out to measure something that had long been hard to pin down: what a person actually feels during active dissociation. They built the Clinician-Administered Dissociative States Scale, or CADSS. It uses 27 items, 19 answered by the person and 8 rated by a trained observer, each scored from 0, meaning not at all, to 4, meaning extremely. The questions ask about the felt experience directly. They cover whether your body or the world around you seems unreal, whether time feels sped up or slowed down, whether you feel detached from yourself, and whether there are gaps in what you can recall. The team grouped these into three areas: derealization, when the world seems unreal; depersonalization, when you feel detached from your own body or self; and amnesia, gaps in memory. They developed and tested the scale with a clinically diverse group of more than 100 people, including trauma survivors, people with other psychiatric conditions, and healthy volunteers, and reported good agreement between raters and good internal consistency. The scores reliably told apart people who were actively dissociating from those who were not.", "study": { "authors": "Bremner, J. D., Krystal, J. H., Putnam, F. W., Southwick, S. M., Marmar, C., Charney, D. S., & Mazure, C. M.", "year": "1998", "title": "Measurement of dissociative states with the Clinician-Administered Dissociative States Scale (CADSS)", "journal": "Journal of Traumatic Stress", "citation": "Journal of Traumatic Stress, volume 11, issue 1, pages 125 to 136", "doi": "10.1023/A:1024465317902", "url": "https://doi.org/10.1023/A:1024465317902" }, "sources": [ "Bremner, J. D., Krystal, J. H., Putnam, F. W., Southwick, S. M., Marmar, C., Charney, D. S., & Mazure, C. M. (1998). Measurement of dissociative states with the Clinician-Administered Dissociative States Scale (CADSS). Journal of Traumatic Stress, 11(1), 125-136. https://doi.org/10.1023/A:1024465317902" ] }, { "id": "how-do-i-prepare-mentally-for-my-next-therapy-session", "question": "How do I prepare mentally for my next therapy session?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/how-do-i-prepare-mentally-for-my-next-therapy-session", "markdown": "https://www.asendar.com/gap/q/how-do-i-prepare-mentally-for-my-next-therapy-session.md", "published": "2026-08-04", "gapNumber": "17 controlled studies of adults in individual therapy, pooled across outcomes", "shortAnswer": "Prepare by getting clear on two things before you go: how therapy works and what you want from the next hour. Research on role induction, a short primer on your part in the process, links this kind of preparation to fewer early dropouts and better results. A few honest notes are enough.", "keyFinding": "Joshua Swift and colleagues at Idaho State University pooled 17 studies that tested role induction, which is a brief primer given at the start of care that explains how therapy works and what the client's part in it will be. Across 15 of those studies, clients who received this preparation were less likely to leave treatment early. The odds ratio was 1.64, which means the odds of staying were about 64 percent higher for prepared clients (p = .03). Preparation also helped the work itself. Across 8 studies it improved what happened inside sessions, a moderate effect of d = 0.64, and across 8 studies it improved results by the end of treatment, a smaller effect of d = 0.33, with both reaching significance (p less than .01). One thing did not: the effect measured partway through treatment, d = 0.26, did not reach significance (p = .30). So the clearest gains showed up at the beginning of care and at the finish.", "study": { "authors": "Swift, J. K., Penix, E. A., & Li, A.", "year": "2023", "title": "A meta-analysis of the effects of role induction in psychotherapy", "journal": "Psychotherapy", "citation": "Psychotherapy, volume 60, issue 3, pages 342 to 354", "doi": "10.1037/pst0000475", "url": "https://doi.org/10.1037/pst0000475" }, "sources": [ "Swift, J. K., Penix, E. A., & Li, A. (2023). A meta-analysis of the effects of role induction in psychotherapy. Psychotherapy, 60(3), 342-354. https://doi.org/10.1037/pst0000475" ] }, { "id": "why-do-i-feel-worse-a-few-days-after-a-session", "question": "Why do I feel worse a few days after a session?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/why-do-i-feel-worse-a-few-days-after-a-session", "markdown": "https://www.asendar.com/gap/q/why-do-i-feel-worse-a-few-days-after-a-session.md", "published": "2026-08-03", "gapNumber": "192 women in trauma-focused therapy for PTSD, pooled from two randomized trials", "shortAnswer": "Feeling worse for a few days after a session is common, and it usually does not mean therapy is failing. In trauma therapy research, a minority of people have a temporary symptom bump, and they still improve by the end. The dip often passes as you process the work.", "keyFinding": "Sarah Larsen and her colleagues pooled data from 192 women receiving trauma-focused therapy for PTSD across two randomized trials. They tracked symptom scores through treatment and counted a reliable worsening as a jump of more than 6 points on a standard PTSD measure. A minority reached that mark, and the rate did not differ in a meaningful way by treatment: about 29 percent in cognitive processing therapy, 20 percent in prolonged exposure, and 15 percent in a version of cognitive processing therapy without a written trauma account. Most people did not have a reliable bump at all. The increases that did happen were not tied to dropping out of therapy, and the people who had them still reached clear, meaningful improvement by the end. The authors read this as evidence that trauma-focused therapy is safe and works, even when it stirs things up along the way.", "study": { "authors": "Larsen, S. E., Stirman, S. W., Smith, B. N., & Resick, P. A.", "year": "2016", "title": "Symptom exacerbations in trauma-focused treatments: Associations with treatment outcome and non-completion", "journal": "Behaviour Research and Therapy", "citation": "Behaviour Research and Therapy, volume 77, pages 68 to 77", "doi": "10.1016/j.brat.2015.12.009", "url": "https://doi.org/10.1016/j.brat.2015.12.009" }, "sources": [ "Larsen, S. E., Stirman, S. W., Smith, B. N., & Resick, P. A. (2016). Symptom exacerbations in trauma-focused treatments: Associations with treatment outcome and non-completion. Behaviour Research and Therapy, 77, 68-77. https://doi.org/10.1016/j.brat.2015.12.009" ] }, { "id": "why-do-old-patterns-come-back-after-therapy", "question": "Why do old patterns come back after therapy?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/why-do-old-patterns-come-back-after-therapy", "markdown": "https://www.asendar.com/gap/q/why-do-old-patterns-come-back-after-therapy.md", "published": "2026-08-03", "gapNumber": "A review integrating decades of controlled extinction experiments in humans and animals", "shortAnswer": "Old patterns come back because therapy does not erase the old learning. It builds new learning on top of it. In the lab, the first response returns when the setting changes, when time passes, or under stress. So a slip is not failure. It means the new path needs more practice.", "keyFinding": "Mark Bouton, a psychologist at the University of Vermont, pulled together decades of experiments on how a learned response fades, a process called extinction that sits underneath a lot of therapy. His central finding is simple and well supported: extinction does not wipe out the original learning. The old association stays intact, and a new one is layered on top that says, in this setting, the old thing no longer applies. Because the new learning is tied to context, the old response can come back in three well documented ways. It returns when the setting changes, which researchers call renewal. It returns as time passes, called spontaneous recovery. And it returns after a stressful reminder, called reinstatement. In other words, the brain keeps both the old track and the new one, and the old track can resurface when the cues line up.", "study": { "authors": "Bouton, M. E.", "year": "2004", "title": "Context and behavioral processes in extinction", "journal": "Learning & Memory", "citation": "Learning & Memory, volume 11, pages 485 to 494", "doi": "", "url": "https://learnmem.cshlp.org/content/11/5/485" }, "sources": [ "Bouton, M. E. (2004). Context and behavioral processes in extinction. Learning & Memory, 11(5), 485-494. https://doi.org/10.1101/lm.78804", "Bustamante, J., Soto, M., Miguez, G., Quezada-Scholz, V. E., Angulo, R., & Laborda, M. A. (2024). Extinction in multiple contexts reduces the return of extinguished responses: A multilevel meta-analysis. Learning & Behavior, 52(3), 209-223. https://doi.org/10.3758/s13420-023-00609-w" ] }, { "id": "does-journaling-after-a-session-actually-help", "question": "Does journaling after a session actually help?", "pillar": "integration", "page": "https://www.asendar.com/gap/q/does-journaling-after-a-session-actually-help", "markdown": "https://www.asendar.com/gap/q/does-journaling-after-a-session-actually-help.md", "published": "2026-07-29", "gapNumber": "146 randomized controlled trials of expressive writing, across clinical and healthy groups", "shortAnswer": "Yes, a little. Research on expressive writing, which means journaling about your thoughts and feelings after something stirs you up, shows a small but real average benefit for how people feel and function. It is not a fix for everything, and it helps most when you write honestly about the emotion, not just the events.", "keyFinding": "Joanne Frattaroli pooled 146 randomized controlled trials of expressive writing, the practice of writing about your thoughts and feelings around an upsetting experience. Across all of them, writing helped more than a neutral control task, with an average effect size of about 0.075, reported as a correlation. That number is small, roughly a Cohen's d of 0.15, so on average the benefit is modest rather than dramatic. The gain showed up across emotional health, reported physical health, and general functioning. It was larger for people working through trauma or hard emotional issues, and larger when people wrote about the feeling rather than only recording events. Frattaroli's read was measured. Expressive writing is a real, low-cost tool that helps a bit for many people, not a strong effect for everyone.", "study": { "authors": "Frattaroli, J.", "year": "2006", "title": "Experimental disclosure and its moderators: A meta-analysis", "journal": "Psychological Bulletin", "citation": "Psychological Bulletin, volume 132, pages 823 to 865", "doi": "10.1037/0033-2909.132.6.823", "url": "https://doi.org/10.1037/0033-2909.132.6.823" }, "sources": [ "Frattaroli, J. (2006). Experimental disclosure and its moderators: A meta-analysis. Psychological Bulletin, 132(6), 823-865. https://doi.org/10.1037/0033-2909.132.6.823" ] }, { "id": "why-does-the-environment-matter-during-a-therapy-session", "question": "Why does the environment matter during a therapy session?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/why-does-the-environment-matter-during-a-therapy-session", "markdown": "https://www.asendar.com/gap/q/why-does-the-environment-matter-during-a-therapy-session.md", "published": "2026-07-25", "gapNumber": "80 volunteers, randomly assigned across four room conditions", "shortAnswer": "The room you sit in shapes the work you do in it. Lighting, comfort, and a sense of safety change how at ease you feel and how openly you speak. In one controlled study, people in a softer, dimmer room felt more relaxed and shared more with the counselor.", "keyFinding": "Yoshiko Miwa and Kazunori Hanyu ran a controlled experiment on how a counseling room's design affects what happens inside it. They built four versions of the same room by crossing two things: the lighting, either bright fluorescent ceiling lights or softer, dimmer lamps, and the decorations, either a plain room or one with home-like touches such as flowers, pictures, and a rug. Eighty people were randomly assigned to one of the four rooms, sat through the same structured interview with the same counselor, and then filled out a questionnaire. The softer, dimmer lighting made the clearest difference. People in the dimly lit rooms reported feeling more pleasant and more relaxed, formed more favorable impressions of the counselor, and disclosed more about themselves than people in the brightly lit rooms. The home-like decorations, by contrast, showed no consistent effect. The authors concluded that the design of a room can shape communication and the sense of connection between a client and a counselor.", "study": { "authors": "Miwa, Y., and Hanyu, K.", "year": "2006", "title": "The Effects of Interior Design on Communication and Impressions of a Counselor in a Counseling Room", "journal": "Environment and Behavior", "citation": "Environment and Behavior, volume 38, issue 4, pages 484 to 502", "doi": "10.1177/0013916505280084", "url": "https://doi.org/10.1177/0013916505280084" }, "sources": [ "Miwa, Y., & Hanyu, K. (2006). The Effects of Interior Design on Communication and Impressions of a Counselor in a Counseling Room. Environment and Behavior, 38(4), 484-502. https://doi.org/10.1177/0013916505280084" ] }, { "id": "what-does-it-mean-to-set-an-intention-before-a-therapy-session", "question": "What does it mean to set an intention before a therapy session?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/what-does-it-mean-to-set-an-intention-before-a-therapy-session", "markdown": "https://www.asendar.com/gap/q/what-does-it-mean-to-set-an-intention-before-a-therapy-session.md", "published": "2026-07-24", "gapNumber": "54 studies, 7,278 people", "shortAnswer": "Setting an intention before a session means naming, in plain words, what you want to work on. It gives the session a direction and gives you and your therapist a shared focus. Research links that kind of agreed direction to better therapy outcomes. It is a focus, not a promise about the result.", "keyFinding": "Georgiana Tryon and her colleagues pooled the results of many separate studies to see whether agreeing on goals shapes how therapy turns out. Across 54 studies with 7,278 people in total, a stronger match between what the client and the therapist were aiming for went with better outcomes. The size of that link was a correlation of about r = 0.24, which researchers count as a medium effect. They found a similar medium-sized link for collaboration, the sense of working together as a team. These are patterns seen across many people, not proof that any single conversation changes a result.", "study": { "authors": "Tryon, G. S., Birch, S. E., & Verkuilen, J.", "year": "2018", "title": "Meta-analyses of the relation of goal consensus and collaboration to psychotherapy outcome", "journal": "Psychotherapy", "citation": "Psychotherapy, volume 55, issue 4, pages 372 to 383", "doi": "10.1037/pst0000170", "url": "https://doi.org/10.1037/pst0000170" }, "sources": [ "Tryon, G. S., Birch, S. E., & Verkuilen, J. (2018). Meta-analyses of the relation of goal consensus and collaboration to psychotherapy outcome. Psychotherapy, 55(4), 372-383. https://doi.org/10.1037/pst0000170" ] }, { "id": "how-do-i-keep-the-gains-from-therapy-over-time", "question": "How do I keep the gains from therapy over time?", "pillar": "maintenance", "page": "https://www.asendar.com/gap/q/how-do-i-keep-the-gains-from-therapy-over-time", "markdown": "https://www.asendar.com/gap/q/how-do-i-keep-the-gains-from-therapy-over-time.md", "published": "2026-07-23", "gapNumber": "28 studies, 1,880 adults treated for depression", "shortAnswer": "Keep practicing the skills therapy gave you, because gains can fade if you stop. Research on cognitive behavioral therapy found that many people slip back over the first two years once active treatment ends. The good news is that continued practice is linked to holding your ground longer.", "keyFinding": "Jeffrey Vittengl and his colleagues pooled 28 studies, covering 1,880 adults treated for depression, to ask a simple question: once therapy ends, do the gains hold? The honest answer was that many did not on their own. After people finished a course of cognitive therapy, about 29 percent slipped back within one year, and about 54 percent slipped back within two years. But the picture was not all loss. People who had done cognitive therapy were less likely to relapse than people whose main treatment was medication that was then stopped. And when therapy continued in a lighter maintenance form after the main work was done, it lowered the odds of slipping back further than the other options the researchers compared. The pattern was steady. The skills helped, and keeping them alive helped more.", "study": { "authors": "Vittengl, J. R., Clark, L. A., Dunn, T. W., & Jarrett, R. B.", "year": "2007", "title": "Reducing relapse and recurrence in unipolar depression: A comparative meta-analysis of cognitive-behavioral therapy's effects", "journal": "Journal of Consulting and Clinical Psychology", "citation": "Journal of Consulting and Clinical Psychology, volume 75, pages 475 to 488", "doi": "10.1037/0022-006X.75.3.475", "url": "https://doi.org/10.1037/0022-006X.75.3.475" }, "sources": [ "Vittengl, J. R., Clark, L. A., Dunn, T. W., & Jarrett, R. B. (2007). Reducing relapse and recurrence in unipolar depression: A comparative meta-analysis of cognitive-behavioral therapy's effects. Journal of Consulting and Clinical Psychology, 75(3), 475-488. https://doi.org/10.1037/0022-006X.75.3.475" ] }, { "id": "what-should-i-do-in-the-two-weeks-between-sessions", "question": "What should I do in the two weeks between sessions?", "pillar": "the-wait", "page": "https://www.asendar.com/gap/q/what-should-i-do-in-the-two-weeks-between-sessions", "markdown": "https://www.asendar.com/gap/q/what-should-i-do-in-the-two-weeks-between-sessions.md", "published": "2026-07-22", "gapNumber": "46 studies, 1,072 clients in cognitive and behavioral therapy", "shortAnswer": "Use the time to practice what your session started. In therapy research this between-session work is called homework, and people who do it tend to do better than people who do not. So keep it simple. Pick one small thing from your session and carry it into your week.", "keyFinding": "Nikolaos Kazantzis and his colleagues pooled 46 studies of cognitive and behavioral therapy, covering 1,072 clients, to test whether between-session homework changes how well therapy works. When they compared the same therapy with and without homework, the versions that included homework came out ahead, with a pooled effect size of about 0.48. That number, called Cohen's d, is a moderate effect, which means a clear and useful difference, not a tiny one and not a miracle. The pattern held up when the authors checked for outliers and for publication bias, and they found no sign that either was driving the result. Their read was steady. Homework was not a minor add-on. It was part of what made the therapy work.", "study": { "authors": "Kazantzis, N., Whittington, C. J., & Dattilio, F. M.", "year": "2010", "title": "Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension", "journal": "Clinical Psychology: Science and Practice", "citation": "Clinical Psychology: Science and Practice, volume 17, pages 144 to 156", "doi": "10.1111/j.1468-2850.2010.01204.x", "url": "https://doi.org/10.1111/j.1468-2850.2010.01204.x" }, "sources": [ "Kazantzis, N., Whittington, C. J., & Dattilio, F. M. (2010). Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17(2), 144-156. https://doi.org/10.1111/j.1468-2850.2010.01204.x" ] }, { "id": "what-does-set-and-setting-mean-in-therapy", "question": "What does set and setting mean in therapy?", "pillar": "immersion", "page": "https://www.asendar.com/gap/q/what-does-set-and-setting-mean-in-therapy", "markdown": "https://www.asendar.com/gap/q/what-does-set-and-setting-mean-in-therapy.md", "published": "2026-07-20", "gapNumber": "654 adults at the start, followed to 212 four weeks later", "shortAnswer": "Set and setting means the two things around a session that are not the treatment itself: your inner state, your mindset and intentions, and the outer environment, the place and the people. A large prospective study found both shape the experience and how you feel in the weeks after.", "keyFinding": "Ekaterina Haijen, Robin Carhart-Harris, and their colleagues followed 654 people who planned to take a plant medicine on their own. They surveyed each person at five points in time, before the experience and up to four weeks after. When the researchers grouped the answers, three factors stood out as shaping the acute experience: set, a person's mindset going in; setting, the environment around them; and having clear intentions. A more positive mindset going in was linked to a lower chance of a hard, challenging experience. On average, wellbeing was higher two weeks after the experience and stayed at that level at four weeks. The authors wrote that the findings support the long-held idea that set and setting are central to how a person responds.", "study": { "authors": "Haijen, E. C. H. M., and colleagues", "year": "2018", "title": "Predicting Responses to Psychedelics: A Prospective Study", "journal": "Frontiers in Pharmacology", "citation": "Frontiers in Pharmacology, volume 9, article 897", "doi": "10.3389/fphar.2018.00897", "url": "https://doi.org/10.3389/fphar.2018.00897" }, "sources": [ "Haijen, E. C. H. M., et al. (2018). Predicting Responses to Psychedelics: A Prospective Study. Frontiers in Pharmacology, 9, 897. https://doi.org/10.3389/fphar.2018.00897" ] }, { "id": "what-is-integration-after-a-therapy-session", "question": "What is integration after a therapy session?", "pillar": "integration", "page": "https://www.asendar.com/gap/q/what-is-integration-after-a-therapy-session", "markdown": "https://www.asendar.com/gap/q/what-is-integration-after-a-therapy-session.md", "published": "2026-07-20", "gapNumber": "886 adults, surveyed before and after a plant medicine experience", "shortAnswer": "Integration is the work of making sense of a therapy session after it ends and turning what surfaced into lasting change. It happens in the days and weeks that follow, through reflection, talking, journaling, and small new habits. The session opens something up. Integration is how it takes root.", "keyFinding": "Joseph Peill, Robin Carhart-Harris, and their colleagues built and tested a short questionnaire, the Psychological Insight Scale, to measure the personal insight people gain from a plant medicine experience. They surveyed 886 adults at several points, from the day after the experience out to four weeks. Insight scores were highest the day after, at a mean of about 64 on a 0 to 100 scale, and stayed high at two and four weeks. Insight the day after was moderately linked to feeling better two weeks later, with a Spearman correlation of about 0.43 (p less than 0.001). In their analysis, insight also helped explain the path from a strong emotional breakthrough during the experience to better wellbeing later. The authors concluded that insight was a key driver of the longer-term change people reported.", "study": { "authors": "Peill, J. M., and colleagues", "year": "2022", "title": "Validation of the Psychological Insight Scale: A new scale to assess psychological insight following a psychedelic experience", "journal": "Journal of Psychopharmacology", "citation": "Journal of Psychopharmacology, volume 36, pages 31 to 45", "doi": "10.1177/02698811211066709", "url": "https://doi.org/10.1177/02698811211066709" }, "sources": [ "Peill, J. M., Trinci, K. E., Kettner, H., Mertens, L. J., Roseman, L., Timmermann, C., Rosas, F. E., Lyons, T., & Carhart-Harris, R. L. (2022). Validation of the Psychological Insight Scale: A new scale to assess psychological insight following a psychedelic experience. Journal of Psychopharmacology, 36(1), 31-45. https://doi.org/10.1177/02698811211066709" ] }, { "id": "does-setting-an-intention-actually-help-you-follow-through", "question": "Does setting an intention actually help you follow through?", "pillar": "intention", "page": "https://www.asendar.com/gap/q/does-setting-an-intention-actually-help-you-follow-through", "markdown": "https://www.asendar.com/gap/q/does-setting-an-intention-actually-help-you-follow-through.md", "published": "2026-07-19", "gapNumber": "94 independent tests", "shortAnswer": "Setting an intention helps most when you turn it into a specific plan. A large research review found that people who spelled out when, where, and how they would act followed through far more often than people who only held a goal in mind. A vague wish moves less than a concrete plan.", "keyFinding": "Peter Gollwitzer and Paschal Sheeran pooled 94 independent tests of what they call implementation intentions, which are simple if-then plans in the form \"if situation Y happens, then I will do X.\" Across those studies, forming an if-then plan had a medium to large effect on reaching a goal, with a Cohen's d of about 0.65. In plain terms, a larger d means a stronger effect, and 0.65 is a meaningful one. People who set a plan for when, where, and how they would act were far more likely to act than people who only set the goal.", "study": { "authors": "Gollwitzer, P. M., & Sheeran, P.", "year": "2006", "title": "Implementation intentions and goal achievement: A meta-analysis of effects and processes", "journal": "Advances in Experimental Social Psychology", "citation": "Advances in Experimental Social Psychology, volume 38, pages 69 to 119", "doi": "10.1016/S0065-2601(06)38002-1", "url": "https://doi.org/10.1016/S0065-2601(06)38002-1" }, "sources": [ "Gollwitzer, P. M., & Sheeran, P. (2006). Implementation intentions and goal achievement: A meta-analysis of effects and processes. Advances in Experimental Social Psychology, 38, 69-119. https://doi.org/10.1016/S0065-2601(06)38002-1" ] } ] }