Summary of Findings: Practice integration/collaborative care positively linked with healthcare professional empathy. Preliminary research has revealed higher level of integrated care is associated with lower levels of burnout. These preliminary analyses set out to explore the relationship between empathy, burnout, and practice integration in primary care. Measures included Consultation and relational empathy (CARE), Practice Integration Profile 1.0 (PIP), and the abbreviated Maslach Burnotu Inventory (aMBI). Analyses included multi-level linear regression with random intercepts for each practice. Covariates included as potential confounders if htey alter the coefficient of hte primary predictor by >10% in the univariate models. Participants included 3,960 patients and 685 healthcare professionals from 44 primary care practices accross the country. Preliminary results revealed that integration appears to be related to patient perceived empathy. Inconsistent results for the PIP and CARE may be due to noise in the PIP (especially at follow-up). Practice workflow and patient engagement may be related to burnout, but small number of practices and variation in levels of measurement were not be ideal for the model.​ Primary care provider burnout may be a better predictor of patient perceived empathy of medical provider as compared to team-based burnout score; however, model may not be ideal without a patient-provider match.​

Clifton, J. & Leibowitz, G. (2021, March). Exploring the relationships among empathy, burnout, and integration (preliminary findings). Invited oral presentation at the Integrated Behavioral Health in Primary Care conference, Virtual.

Abstract: Occupational burnout is a major concern for personal well-being and patient care. We examined burnout among primary care providers (PCPs), medical residents, behavioral health providers (BHPs), nurses, and other clinical and nonclinical primary care team members. This was a cross-sectional study, nested within a larger randomized trial. Participants completed a validated 9-item burnout measure with 3 domains: depersonalization, emotional exhaustion, and personal accomplishment. Multivariable multilevel linear regression with a random intercept for each practice was used to determine mean differences in burnout across professional roles. Overall burnout rates varied by professional role: PCPs 70%, medical residents 89%, BHPs 59%, nurses 66%, other clinicians 68%, and nonclinical professionals 70%. Compared with nonclinical professionals, residents experienced more burnout in more domains, followed by PCPs. PCPs, residents, and nurses reported significantly worse depersonalization and exhaustion scores. Nonclinical professionals had worse accomplishment scores than all clinical professionals except for residents. This study revealed moderate-to-high levels of burnout among primary care professionals. Clinicians may be experiencing aspects of burnout more intensely than their nonclinical colleagues, and this may be most true for residents and PCPs. Based on these variations, interventions to mitigate burnout may need to be tailored by professional role.​

Clifton, J., Bonnell, L.N., Hitt, J., Crocker, A., Rose, G., van Eeghen, C., Kessler, R., Stephens, K., Teng, K., Leon, J., Mollis, B., Littenberg, B. (2021). Differences in occupational burnout among primary care professionals. Journal American Board of Family Medicine, 34(6):1203-1211, doi:10.3122/jabfm.2021.06.210139.

Abstract: A movement towards integrated behavioral health (IBH) in primary care continues to grow, among an accumulating evidence base for its effectiveness for improving care. However, healthcare organizations struggle to navigate where to target their limited resources for improving integration. We evaluated a cross-model framework of IBH core processes and structures. We used a mixed-methods approach for evaluation of the framework, which included (a) an evaluation survey of national experts and stakeholders, (b) crosswalks with common IBH measures, and (c) a real-world usability test. Five core IBH principles, mapping to 25 processes, and nine clinic structures were defined. Survey responses from 29 IBH domain and policy experts and stakeholders resulted in uniformly high ratings of importance and variable levels of feasibility for measurement, particularly with respect to electronic health record (EHR) systems. A real-world usability test resulted in good uptake and use of the framework across a state-wide effort. An IBH Cross-Model Framework of core principles, processes, and structures generated good acceptability and showed good real-world utility in a state-wide effort to improve IBH across disparate levels of integration in diverse primary care settings. Findings identify feasible areas of measurement, particularly with EHR systems. Next steps include testing the relationship between the individual framework components and patient outcomes to help guide clinics towards prioritizing efforts focused on improving integration.

Stephens K.A., van Eeghen C., Mollis B., Au M., Brennhofer S.A., Martin M., Clifton J., Witwer E., Hansen A., Monkman J., Buchanan G., Kessler R. Defining and measuring core processes and structures in integrated behavioral health in primary care: A cross-model framework. Transl Behav Med, 10(3):527-538, doi: 10.1093/tbm/ibz163.

Abstract: To determine if an internet-based mind/body program would lead to participants experiencing infertility (1) being willing to be recruited and randomized and (2) accepting and being ready to engage in a fertility-specific intervention. Secondary exploratory goals were to examine reduced distress over the course of the intervention and increased likelihood to conceive. This was a pilot randomized controlled feasibility trial with a between-groups, repeated measure design. Seventy-one women self-identified as nulliparous and meeting criteria for infertility. Participants were randomized to the internet-based version of the Mind/Body Program for Fertility or wait-list control group and asked to complete pre-, mid- and post-assessments. Primary outcomes include retention rates, number of modules completed, and satisfaction with intervention. Secondary exploratory outcomes sought to provide preliminary data on the impact of the program on distress (anxiety and depression) and self-reported pregnancy rates relative to a quasi-control group. The retention, adherence, and satisfaction rates were comparable to those reported in other internet-based RCTs. Although time between pre- and post-assessment differed between groups, using intent-to-treat analyses, women in the intervention group (relative to the wait-list group) had significant reduction in distress (anxiety, p = .003; depression, p = .007; stress, p = .041 fertility-social, p = .018; fertility-sexual, p = .006), estimated as medium-to-large effect sizes (ds = 0.45 to 0.86). The odds of becoming pregnant was 4.47 times higher for the intervention group participants as compared to the wait-list group, OR 95% CI [1.56, 12.85], p = .005 and occurred earlier. The findings suggest that the research design and program specific to this population are feasible and acceptable. Replication efforts with an active control group are needed to verify distress reduction and conception promotion findings.​

Clifton, J., Parent, J., Seehuus, M., Worrall, G., Forehand, R., Domar, A. (2020). An internet-based mind/body intervention to mitigate distress in women experiencing infertility: A randomized pilot trial. PlosONE, 15(3), doi:10.1371/journal.pone.0229379.

Abstract: Numerous psychological constructs exist to describe different facets of emotional responding, but they have rarely been examined together. We empirically modeled the associations between four psychological constructs (mindfulness, emotional nonacceptance, experiential avoidance, and anxiety sensitivity) of individuals' responses to their affective experience, hypothesizing that a bifactor model would fit the data best. We used exploratory structural equation modeling, a novel latent variable modeling framework, to compare five measurement models of emotional responding in an online community sample (N = 307). A bifactor model including a general emotional responding factor had substantial factor loadings from nearly all items, with mixed results for specific factors. Exploratory analyses supported the significant association of avoidant emotional responding and psychopathology/well-being. The general avoidant emotional responding factor appears to overlap most directly with experiential avoidance and may be a transtheoretical construct relevant to mental health.

Clifton, J., Seehuus, M., Parent, J., Pichler, E., & Fondacaro, K. (2020). Emotional responding: Integration of multiple constructs and association with psychological health. Journal of Clinical Psychology, 76(4), 699-715. doi.org/10.1002/jclp.22885.

Abstract: Many practice innovations do well in small studies at one or a few sites, but are never deployed broadly. Objective: To test the impact of integrating behavioral health (BH) and primary care (PC) at scale. Design: Cluster-randomized pragmatic clinical trial. Setting: 45 PC clinics of all types in 11 states. Eligible clinics already had a co-located BH provider. Population: Adults with both chronic medical and BH concerns. Intervention: Structured practice redesign to enhance integration of BH and PC using a toolkit of workflow tactics, online education for clinicians and staff, remote coaching of practice staff, and an online learning community. A standardized assessment tool (the Practice Integration Profile) informs local clinic’s redesign efforts and provides an intermediate outcome. Outcome Measures: Patient functional status, degree of practice integration, costs of integration. Results: Nearly 4,000 subjects have completed baseline assessment. 22 practices have successfully deployed the toolkit; 1 withdrew. The intervention must be flexible in specifics to support local needs and culture but consistent in overall goals to support policy goals. Expected outcomes: Evidence on the patient and practice impacts, feasibility, and costs of integrating BH and PC. Insight into barriers to, and facilitators of, successful real-world integration. A model for testing practice-level innovations at scale.​

Littenberg B., Macchi C., Kessler R., Pace, W., Bonnell, L., Rose, G., Hitt, J., Natkin, L., Lavoie, J., Crocker, A., Clifton, J., van Eeghen, C. (2019, November). A large pragmatic clinical trial of Behavioral Health in Primary Care as a model of testing practice innovations at scale. Oral presentation at the North American Primary Care Research Group, Toronto, ON.

Abstract: Primary care practice redesign benefits from facilitation. External facilitation (i.e. coaching) of internal practice facilitators assists practices by providing expert, nonjudgmental support and guidance on navigating a complex redesign process. In practice, coaches exhibit varied styles to support facilitators but a tool for evaluating coaching style does not exist. We do not know if different styles are associated with different coaching outcomes or the degree to which coaching style is part of a reciprocal system of coaching, in which the person being coached plays a role. Previous work has described coaching style in terms of both the function of a coach and the approach a coach can choose in supporting an internal practice Quality Improvement (QI) facilitator. A group of coaches, actively engaged in supporting practice QI facilitators, evaluated their coaching styles individually and in paired teams. They found differences in approach among group members and opportunities for improvement, both for personal development and for mutual support as coaching partners. A literature search yielded multiple domains to describe coaching styles within the field of primary care practice redesign. Before embarking on a QI project for performance improvement, they sought to collect feedback from facilitators. Coaches created a coaching assessment instrument that was tailored to their coaching values and supported both function and approach characteristics of coaches. They plan to use this instrument to collect data about coaching style to support a Coaching QI project This report provides a work-in-process view of the translation of the definition of coaching style into a coaching QI activity, with the goal of increasing our understanding of what coaching style means and how we can act on it to improve our work. This QI effort includes the development of a feedback assessment of coaching style, collection of data from internal practice facilitators (n=25) about the coaches, analysis of those results, and development of the first cycle of plans for individual coaches in improving coaching style. This report is a continuation of a presentation in December 2018 at ICPF. This project is part of a large, pragmatic, comparative effectiveness trial of a protocolized quality improvement initiative to integrate behavioral health in primary care practices (n = 43) across the U.S. Practices randomized to the intervention arm (n=21) selected an internal facilitator to guide a small group of practice staff and providers through the intervention and engage with an external coaching dyad. Dyads included an expert in practice facilitation and a psychologist with knowledge of health services research. All coaches (n=5) were instructed to use the same coaching model to frame their interactions with practices, while operating within a randomized trial. Coaches held weekly meetings to discuss coaching style and coaching issues. Coaches used information from the literature search to create a framework of coaching values and a coaching assessment survey that will be distributed to 25 internal practice facilitators in April/May 2019. Data was analyzed using descriptive statistics. Responses to the assessment were summarized by coach, dyad, and coaching team as a whole about the following improvement opportunities: 1) coaches’ application of their values, 2) performance of coaching function, and 3) delivery of coaching approach. Results will support the start of Plan/Do/Study/Act cycles for quality improvement of external coaching. This presentation shared plans for coaching style improvement and invited the audience to discuss relevance, generalizability, and innovations seen in coaching quality improvement. Coaching style is an important characteristic in the effective delivery of coaching services to support internal practice facilitators. Further work in this area will identify how to refine our measurement of coaching style and how to study its effect on QI facilitators.

van Eeghen, C., Bryan, L., Clifton, J., Rose, G., Messier, R. (2019, June). From coaching style to coaching quality improvement: Case study example. Oral presentation at the North American Primary Care Research Group, Bethesda, MD.

Abstract: Systematic reviews and some recent studies have suggested that anxiety plays a role in reducing chances of becoming pregnant1, although the literature is not yet settled. The primary goal of this study was to further explore trait anxiety as a predictor of fertility treatment outcome in patients seeking treatment at an academic reproductive clinic serving a rural population in the northeastern United States. This is a prospective cross-sectional study. Anxiety symptomology was assessed through self-report using the Brief Symptom Inventory (BSI) subscales Phobic Anxiety (PA, e.g., “Feeling uneasy in crowds, such as shopping or at a movie”), Anxiety (A, e.g., “Feeling tense or keyed up”), and Obsessive-Compulsive (OC, e.g., “Having to check and double-check what you do”). Fertility treatments are defined as ovulation induction and IVF. Fertility treatment outcomes (i.e., positive pregnancy test at two weeks following intervention) were obtained through medical chart review. Thirty-three women were recruited and assessed during their first appointment to the clinic. Results: After controlling for age, body mass index (BMI), and insurance coverage for reproductive care, anxiety symptomology significantly predicted fertility treatment outcomes. This model explained a significant proportion of variance in outcomes, R2 = .42, F(2 , 26) = 3.17, p =.018. All three anxiety subscales - PA (β = -.75, p = .001); A (β = .79 , p = .01); OC (β = -.47, p = .05) had a negative predictive value for a successful treatment. More broad analysis of clusters of symptomology underlying anxiety disorders, demonstrate that an increase in anxiety symptoms, specifically phobic and obsessive-compulsive symptomology, is related to a decrease in pregnancy rates following fertility treatment. Results of this study further support the body of research that trait anxiety plays a predictive role in the outcome of fertility treatment and suggest that identifying and treating anxiety in patients undergoing fertility treatment could improve outcomes. In addition to improving fertility treatment outcomes, early screening and intervention for anxiety could also benefit more long-term outcomes such as maternal well-being and birth outcomes.

Saiki, K., Clifton, J., Seehuus, M., Worrall, G., Casson, P.R., Rellini, A., Raj, R., & McGee, E. (2016, October). Anxiety symptoms as predictors of fertility treatment outcomes. Poster presentation at the American Society for Reproductive Medicine, Salt Lake City, UT.

Abstract: Psychological inflexibility and experiential avoidance have been associated with negative outcomes, including depression, anxiety, and mental health problems in general. Furthermore, these psychological processes have shown to mediate the impact of Acceptance and Commitment Therapy (ACT) on mental health problems. Research has also demonstrated the importance of treatment engagement in psychotherapy outcomes. However, very little is known about the relationship between these variables in non-Western cultures. The present feasibility study examined changes in psychological inflexibility and experiential avoidance in a group of 13 female Bhutanese refugees seeking services at a community clinic. These women were assessed and invited to join an open-ended group with ongoing enrollment. Weekly group psychotherapy sessions were oriented in ACT principles and aimed to enhance psychological wellbeing. We utilized the Acceptance and Action Questionnaire (AAQ-II) to assess for psychological inflexibility and experiential avoidance at two mid-treatment time points (approximately 25 weeks and 50 weeks). Group psychotherapy treatment and assessment were performed with the assistance of a Nepali interpreter(s). Descriptive statistics indicated a decrease in mean scores on the AAQ-II (25 weeks: M = 44.2, SD = 26.05; 50 weeks: M = 37.4, SD = 8.74). Although not statistically significant (t(4) = .787, p = .47), this difference speaks to the clinical utility of using an ACT framework with this population. Additionally, a moderation analysis revealed that the number of treatment sessions attended may play a role in changes in psychological inflexibility and experiential avoidance, thus suggesting a dose-response relationship (F(3)=74.29, p = 0.08). Despite the exploratory nature and statistical limitations due to small sample size, this study provides support for (1) addressing psychological inflexibility and experiential avoidance in group therapy with non-English speaking refugees using ACT principles; (2) continuing to examine the use of ACT constructs with validated measurements in this population; and (3) understanding the impact of group attendance on changes in psychological flexibility. Overall, these results add new and relevant information to the extant literature by demonstrating the feasibility and utility of doing group therapy and research with non-English speaking refugees using an ACT framework. Future research should assess for barriers involved with attending therapy (e.g., avoidance, transportation, pain) and explore how psychological inflexibility and experiential avoidance are involved.

Clifton, J., Ho, S, Baetz, C., Pichler, E., Evans, M, Gottlieb, G., Harder, V., & Fondacaro, K. (2015, July). A Preliminary investigation of the use of acceptance and commitment therapeutic principles in group treatment with a community sample of Bhutanese refugee women. Poster presented at the Association for Contextual Science, Berlin, Germany.

Abstract: Refugee parents face unique challenges raising adolescents that are assimilating into Westernized culture given their past experiences, cultural differences (e.g., views on adolescent autonomy), and unfamiliarity of parenting practices in their new environment. These factors may lead to an increase in negative adolescent behavior, psychopathology, and familial stress. Behavioral parenting programs targeting common adolescent behavior may be one method of reducing these effects. However, given the unique experiences of refugee parents, it is important to incorporate culturally-adapted methods to previously established parenting programs. Psychological flexibility may enhance the effects of parenting training, as the parent is able to engage with the material and their adolescent despite the challenges they experience. The current study will present a modified adolescent parenting program designed for refugee parents rooted in ACT principles. We will examine the association between parental psychological flexibility in predicting treatment change in parenting style and adolescent behavior. We predict greater psychological flexibility will be associated with greater gains in parenting skills and a reduction in adolescent psychopathology.

Brassell, A., Parent, J., Clifton, J., & Fondacaro, K. (2015, July). The role of psychological flexibility in predicting treatment response for a behavioral parenting program. Poster presented at the Association for Contextual Science, Berlin, Germany.

Abstract: The literature on sexual responses shows a large and not fully understood between-women variance in sexual responses and in strength of coherence between physiological and subjective sexual responses. This study investigated cognitive factors theorized to be associated with sexual responses that could explain such variance. Specifically, we investigated the predictive value of sexual excitation/inhibition and sexual schemas on sexual response and coherence. Vaginal photoplethysmography and continuous subjective sexual arousal were collected from 29 young women while they watched a control/erotic video sequence. Hierarchical linear modeling revealed that high sexual excitation and schemas related to passion and romance were related to higher coherence. These findings support the notion that cognitive factors that enhance sexual arousal contribute to the large variation seen in the coherence of sexual response as measured in the laboratory.

Clifton, J., Seehuus, M., & Rellini, A. (2014). Testing cognitive predictors of individual differences in the sexual psychophysiological responses of sexually functional women. Psychophysiology, 52(7), 957-968, doi: 10.1111/psyp.12423.

Abstract: Cohabitation is a family structure experienced by many Black children; yet, we have limited understanding of how personal and interpersonal processes operate within these families to influence the parenting provided to these children. Informed by both family systems theory and the spillover hypothesis and utilizing a model to account for the interdependence of the mother and her partner, the current study sought to understand the direct and indirect associations among parental mindfulness, the mother-partner relationship quality, and firm parenting practices in a sample of 121 Black cohabiting low-income stepfamilies. Assessment consisted of standardized measurements of maternal and male cohabiting partner reports on mindfulness (i.e., acting with awareness) and relationship quality (i.e., relationship satisfaction, ability to resolve conflict, and coparenting conflict) as well as adolescent report on parenting (i.e., parent's firm control). Mindfulness was directly related to each individual's own perceptions of relationship quality and some support emerged for a cross-informant link (e.g., mother's mindfulness related to partner report of relationship quality). Furthermore, maternal perceptions of relationship quality, as well as mindfulness operating through relationship quality, were related to youth reports of maternal firm parenting. The results suggest that both mindfulness and the relationship quality of adults are variables deserving attention when studying the parenting received by children in cohabiting stepfamilies. Clinical implications of the findings are considered.

Parent, J., Clifton, J., Forehand, R., Reid, M., Golub, A., & Pichler, E. R. (2014). Parental mindfulness and dyadic relationship quality in Black cohabiting stepfamilies: Associations with parenting experienced by adolescents. Couple and Family Psychology, 32(2), 67-82, doi: 10.1037/cfp0000020.

Summary of Presentation: Discussed key issues for torture and trauma survivors (eg, safety, survival, trust), interdisciplinary holistic perspectives, addressing post-migration factors (barriers to healing, complex trauma), pre-existing stressors (eg, chronic health conditions, poverty, racism and gender issues), post-migration stressors (eg, language, securing basic needs, roles/identity, legal issues), recovery and interventions (eg, restoring safety and support networks, patient centered, collaboration, advocacy, group psychological interventions), skill building using cultural sensitive resources, working with interpreters, and case examples.

Clifton, J., Kelley, C., Green, A. (2013) Addressing post migration factors: Medical and social work interventions. New England Survivors of Torture and Trauma Conference, Burlington, VT.

Abstract: Women with a history of childhood sexual abuse (CSA) experience dissociative symptoms and sexual difficulties with greater frequency than women without a history of CSA. Current models of sexual dysfunction for sexual abuse survivors suggest that dissociation may mediate the relationship between CSA and sexual arousal difficulties. Dissociation, however, is often conceptualized as a single construct in studies of CSA and not as separate domains as in the dissociation literature. In the present study, women with (CSA, N = 37) and without (NSA, N = 22) a history of CSA recruited from the community were asked to indicate the frequency and intensity of their experience in two dissociation subgroups, derealization and depersonalization, during sex with a partner and in their daily life. Findings showed that, in the NSA group, more depersonalization during sex with a partner was associated with lower sexual arousal functioning. However, for both the NSA and CSA groups, more derealization during sex was associated with higher sexual arousal functioning. No measure of dissociation was significantly associated with sexual responses in the laboratory. These findings highlight the importance of distinguishing between different forms of dissociation (i.e., derealization and depersonalization) in the study of sexual arousal functioning. In addition, the findings challenge the notion that dissociation is a main predictor of sexual arousal problems in survivors of CSA and suggest that a more nuanced relationship may exist.

Clifton, J., Kelley, C., Green, A. (2013) Addressing post migration factors: Medical and social work interventions. New England Survivors of Torture and Trauma Conference, Burlington, VT. Bird, E.R., Seehuus, M., Clifton, J., & Rellini, A.H. (2013). Dissociation during sex and sexual functioning in women with and without a history of childhood sexual abuse. Archives of Sexual Behavior, 43(5), 953-964, doi: 10.1080/0092623X.2015.1124304.

Abstract: Torture among refugees and asylum seekers has been associated with psychological consequences; however, there is little research exploring the effects of the type of torture on psychopathology. This study examines the relationship between number and type of torture predicting anxiety, depression, and posttraumatic stress disorder (PTSD) scores. This study assessed 26 adult survivors of torture and trauma seeking mental health services in Vermont completed measures assessing PTSD (Harvard Trauma Questionnaire), anxiety, and depression (Hopkins Symptom Checklist) symptoms. Based on the responses on the HTQ and demographics form, torture and trauma were classified into one or more of the following categories: witnessed trauma, family torture, beating, rape/sexual assault, and deprivation. Multiple linear regressions was used to examine the association between type of trauma and psychopathology as well as the impact of increasing number of types of torture. Results showed that rape/ sexual assault (b = 19.93, t[18] = 2.74, p < .05) and deprivation (b = 21.51, t[18] = 2.16, p < .05) served as significant predictors of PTSD symptoms. The number of torture types experienced was significantly related to PTSD symptoms (R2 = .36, F[1,20] = 11.35, p < .05), such a greater number of torture types experienced was associated with higher levels of PTSD symptoms. A significant linear relationship was not found between type of trauma or number of torture types experienced and anxiety or depressive symptoms. The results of this study suggest that rape/sexual assault and deprivation are more likely to lead to increased levels of PTSD symptoms than other types of torture. Furthermore, the more types of torture reported appear to lead to more severe PTSD. These results may help conceptualize torture in terms of categories that lead to PTSD problems and guide prevention and treatment for refugees and asylum seekers. This poster will be able to provide attendees with the following information (1) a comparison between refugee and non-refugee populations, (2) a classification of categories of torture used in the literature, (3) assessment techniques for type of torture experienced when treating clients with PTSD, and (4) skills on how to recognize the potential predictors of PTSD symptomology in torture survivors.

Clifton, J., Evans, M., Harder, V. S., & Fondacaro, K. (2012, April). The relationship between types of torture and psychological functioning. Poster presented at the Anxiety Disorders Association of America, Arlington, VA.

Abstract: Although analyzing negative experiences leads to physical and mental health benefits among healthy populations, when people with depression engage in this process on their own they often ruminate and feel worse. Here we examine whether it is possible for adults with depression to analyze their feelings adaptively if they adopt a self-distanced perspective. We examined this issue by randomly assigning depressed and nondepressed adults to analyze their feelings surrounding a depressing life experience from either a self-distanced or a self-immersed perspective and then examined the implications of these manipulations for depressotypic thought accessibility, negative affect, implicit and explicit avoidance, and thought content. Four key results emerged. First, all participants were capable of self-distancing while analyzing their feelings. Second, participants who analyzed their feelings from a self-distanced perspective showed lower levels of depressotypic thought accessibility and negative affect compared to their self-immersed counterparts. Third, analyzing negative feelings from a self-distanced perspective led to an adaptive shift in the way people construed their experience--they recounted the emotionally arousing details of their experience less and reconstrued them in ways that promoted insight and closure. It did not promote avoidance. Finally, self-distancing did not influence negative affect or depressotypic thought accessibility among nondepressed participants. These findings suggest that whether depressed adults' attempts to analyze negative feelings lead to adaptive or maladaptive consequences may depend critically on whether they do so from a self-immersed or a self-distanced perspective.

Kross, E., Deldin, P., Gard, D., Clifton, J., & Ayduck, O. (2012). "Asking why" from a distance: Its cognitive and emotional consequences for people with Major Depressive Disorder. Journal of Abnormal Psychology, 121(3), 559-569.

Abstract: Female orgasmic disorder (FOD) is defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, as a persistent or recurrent delay in, or absence of, orgasm following a 'normal' sexual excitement phase. FOD is a common problem affecting sexual function in a substantial proportion of women. Studies suggest that it is prevalent in 11-41% of women worldwide and can have a tremendous impact on the individual's quality of life, relational satisfaction and general well-being. The etiology of FOD tends to be multifactorial as it relates to genetics, medical conditions, medications, alcohol and drug use, other sexual dysfunctions, mental illness, life stressors, communication deficits and relationship issues. It is critical that sexual functioning in patients is assessed frequently through interview and/or validated questionnaires to aid in treatment strategy and/or referral. Currently, there are no approved medications to treat FOD. However, there are medications and psychological treatments that have shown promise in either treating FOD or thwarting the side effects of medications that can cause FOD. This chapter discusses the epidemiology and etiology of FOD and provides a comprehensive critical review of the literature on assessment and treatment of FOD.

Rellini, A. & Clifton, J. (2011). Female orgasmic disorder. In. R. Balon (Ed.), Advances in Psychosomatic Medicine (Vol 31, pp. 35-56). Basel, Switzerland: Karger, doi: 10.1159/000328807.

Abstract: Emotions activated implicitly (below the awareness threshold) affect decision making and avoidance behavior. While the literature has mostly focused on threat stimuli, relatively little is known on the effects of both threat and sexual subliminal stimuli on sexually-relevant behavior. This study investigates the validity of a new method to assess the activation of emotions in response to implicit sex and threat stimuli and the effect of these implicit emotions on protective avoidance behavior relevant to risky sexual situations. Women (N = 44) ages 18-23, were asked to complete the ACTivation Task (ACT). In the ACT emotional responses are primed by 3 types of subliminal stimuli (below the awareness threshold): Neutral, Sex, and Threat. Primes were followed by a picture of a young man. Participants were asked to quickly respond if they would accept a ride after a party from the depicted man. Also, participants completed the Trauma History Questionnaire (THQ; Green, 1996), a measure of physical and sexual abuse (PSA). Main Outcome Measures: Reaction time (RT; msec) was operationalized as a measure of avoidance behavior when the participants responded NO (rtNO), and approach behavior when they responded YES (rtNO) in the ACT task. Results: Findings showed a significant effect of Condition (Neutral, Sex, Threat) on rtNO F(2, 39) = 4.99, p < .01. Faster rtNO occurred in the Threat compared to the Neutral condition, p < .01, and in the Threat compared to the Sex condition, p < .01. There were no effects of Condition on rtYES. Also no main or interaction effects were observed for a history of sexual abuse and sexual abuse X Condition. Conclusions: This study provides evidence that ACT is a valid measure of how emotions primed by threat stimuli affect behavior relevant to sexual behavior. Future studies interpolating the effect of explicit sexual stimuli (above the awareness level) may be able to provide a more complete picture of the role of emotions activated by sexual and threat subliminal stimuli in decision making. Understanding the role of emotion activation in risky decision making could add to the improvement of prevention programs seeking to reduce revictimization.

Clifton, J., Rellini, A.H., Burt, K., & Jannsen, E. (2011, February). Implicit emotional processes affect sexually-relevant behavior. Oral presentation at the International Society for the Study of Women's Sexual Health, Scottsdale, AR.

Abstract: Various studies regarding the universality of emotive expression have contributed to the proposition that emotions are part of an evolutionary, adaptive function in response to ever-changing environmental stimuli. In addition, artistic renderings throughout human history have relied on the portrayal of emotive expression, particularly through facial expression, to convey the context and intent of the chosen subject or theme. Combining the disciplines of psychology and art history, the following descriptive review presents similar artistic emotive expressions across cultures and time periods to provide further evidence that certain emotive expressions are an innate or universal part of human nature. The following review found the facial expression of happiness in subjects depicted in painting, sculpture, and other artistic mediums across three cultures and time epochs; obtained independent sources as validation of the artist’s or genre’s intention to portray the specific emotion; and used the Facial Action Coding System (FACS) to code the facial expressions of the subjects in the art pieces. Results found similar facial expressions across time epochs and cultures, bolstering previous empirical findings in support of the universality of emotive facial expressions.

Wilson, J., Clifton, J., & Matsumoto, D. (2007, May). Emotive facial expressions in art. Poster presentation at the Western Psychological Association, Vancouver, Canada.