Absence of evidence or evidence of absence: reflecting on therapeutic implementations of attentional bias modification

Clarke, Patrick JF; Notebaert, Lies; MacLeod, Colin · 2014 · OpenAlex-citations

DOI: 10.1186/1471-244x-14-8

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Summary

This commentary addresses the debate surrounding the therapeutic efficacy of Attentional Bias Modification (ABM), a cognitive intervention designed to reduce anxiety by altering selective attention toward threatening stimuli. The authors respond to recent critiques, particularly a review by Emmelkamp, which argued that ABM lacks clinical utility and should not be pursued as an online intervention due to failed randomized controlled trials (RCTs), such as one by Carlbring et al. Clarke et al. contend that these failures represent an "absence of evidence" rather than "evidence of absence," arguing that the theoretical basis for ABM remains sound and that further research is warranted. The authors analyze the existing literature by contrasting successful ABM implementations with recent failures. They highlight early RCTs demonstrating significant clinical benefits: Schmidt et al. found that 72% of social anxiety patients no longer met diagnostic criteria after ABM, compared to 12% in controls; Amir et al. reported similar reductions in social anxiety (50% vs. 14%) and generalized anxiety disorder (50% vs. 13%). The authors also review two meta-analyses, noting that while Hallion and Ruscio reported small effect sizes due to methodological flaws (e.g., pooling incompatible studies), Hakamata et al. found medium effect sizes (d = 0.61), with larger effects in clinical populations (d = 0.78). Crucially, the authors compiled data from 29 studies measuring both attentional change and emotional vulnerability. They found that in 26 of these studies, emotional benefits occurred only when attentional bias was successfully modified. In studies where ABM failed to alter attention, it also failed to reduce anxiety, indicating manipulation failure rather than therapeutic ineffectiveness. The authors refute claims that positive ABM results are driven by demand or expectancy effects. They argue that ABM tasks use tightly matched control conditions, making it difficult for participants to discern their group allocation; indeed, 79% of control participants believed they were not receiving active treatment. This design minimizes non-specific factors that often inflate results in traditional cognitive behavioral therapy (CBT) trials. Furthermore, the authors challenge the notion that existing online treatments preclude ABM research, noting that ABM offers a simpler, briefer alternative to multi-week CBT protocols, with potential for high effect sizes (up to d = 1.92) in short durations. The significance of this commentary lies in its defense of ABM as a promising, albeit immature, therapeutic tool. The authors conclude that the field should focus on optimizing task parameters to reliably modify attentional bias, rather than abandoning the approach. They suggest that future research should investigate factors influencing task adherence, such as participant beliefs about treatment efficacy, and explore how ABM might be integrated with traditional therapies. The paper asserts that the consistent link between attentional change and emotional improvement validates the causal mechanism of ABM, warranting continued investment in refining its clinical application.

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• inattentional change blindness