Articles

Special Issue on Cognitive Vulnerability and Attachment
Nathan L. Williams and John H. Riskind, Editors

The articles in this special issue address empirically the application of attachment theory to cognitive vulnerability models of anxiety and depression. The findings from these studies converge on the theme that attachment theory has considerable utility in potentially extending and refining current vulnerability models through a consideration of interpersonal context and the cognitive mechanisms by which negative interpersonal experiences may confer increased risk to later anxious and depressive symptoms.

Adult romantic attachment and cognitive vulnerabilities to anxiety and depression: Examining the interpersonal basis of vulnerability models
Nathan L. Riskind and John H. Riskind

Bowlbyâ??s attachment theory contends that all individuals develop working models of self and significant others, based on early experiences, that have important implications for understanding adult psychopathology. From a social cognitive perspective these â??working modelsâ? can be conceptualized in terms of relational schemas that have the same functions as other types of schemas (e.g., organizing information, guiding future behavior, etc.). Cognitive vulnerability models have proposed a pessimistic explanatory style that confers vulnerability to depression and a looming maladaptive style that confers vulnerability to anxiety. The present study examines the pattern of relationships between adult romantic attachment, cognitive vulnerabilities to anxiety and depression, self-reported anxious and depressive symptoms, and both general and specific relationship outcomes. Results suggest that higher levels of attachment insecurity were associated with increased psychological symptoms, higher levels of cognitive vulnerabilities, and lower relationship and general life satisfaction, and increased health concerns over the previous six months. Moreover, cognitive vulnerabilities partially mediated the relationship between adult attachment and anxious and depressive symptoms, suggesting that insecure attachments may represent a developmental antecedent to cognitive vulnerabilities to anxiety and depression.

The relationship of cognitive style and attachment style to depression and anxiety in young adults
Scott M. Saffford, L. Lauren B. Alloy, Alisa O. Crossfield, Antonia M. Morocco, and James C. Want

This study examined the associations between attachment style and cognitive style and depression and anxiety symptomatology. Using a college sample of 167 participants, the tripartite model of depression and anxiety (Clark & Watson, 1991) was employed to examine whether the construct of negative affectivity could account for the previously reported relationships between insecure attachment style and negative cognitive style and both depression and anxiety. Negative cognitive style and insecure attachment were found to be significantly associated with both depression and anxiety symptomatology. Although negative affectivity effectively accounted for the relationships between negative cognitive style and both depression and anxiety and could explain the relationship between insecure attachment and anxiety, it failed to account for the association between insecure attachment and depression. In addition, negative cognitive style and insecure attachment appeared to be independently and uniquely associated with negative affect, rather than forming a mediational relationship.

Developmental Antecedents of the looming maladaptive style: Parental bonding and parental attachment insecurity
John H. Riskind, Nathan, L. Williams, Melissa D. Altman, David O. Black, Mark S. Balaban, and Theodore L. Gessner

Considerable research has supported links between disrupted parental bonding, attachment insecurity, and psychopathology. Still, few studies have attempted to integrate these findings within a broader cognitve theory of anxiety. Two studies are presented that examine the links between cognitive vulnerability to anxiety (i.e.e., the Looming Maladaptive Style; LMS) and parental bonding (study 1) and perceived parental attachment orientations during childhood (study 2). Results of Study 1 suggest that low levels of maternal overprotection and high levels of paternal overprotection significantly predict LMS scores, beyond the effects of current anxious and depressive symptoms. Results of Study 2 suggest that retrospective reports of maternal attachment insecurity are associated with significantly higher LMS scores, anxious and depressive symptoms, adult romantic attachment insecurity, and potentially high-risk relationship behaviours. These results are interpreted from the perspective of the Looming Vulnerability Model of anxiety and may increase understanding of the linkage between childhood developmental antecedents and cognitive risk for anxiety.

Emotional information processing and disrupted parental bonding: Cognitive Specificity and avoidance
Rick E. Ingram, Kelly Bailey, and Greg Siegle

Although studies have assessed the association between affective dysfunction and parental bonding, little research has assessed the information processing characteristics of individuals with disrupted parental bonding. The current study investigated differences in attentional processing between individuals with relatively poor versus secure parental bonding, and also assessed this processing in conjunction with a mood priming procedure that has been used in previous vulnerability research. Using a Stroop procedure, results indicated that poorly bonded individuals were less distracted by depressive information than were individuals reporting a secure bonding history. Results also suggested that avoidance of anxious information in the poorly bonded group was uniquely associated with maternal overprotection. These results suggest that poorly bonded individuals may cope with their increased vulnerability by avoiding some types of affectively-linked information, and that some of this avoidance may be linked to perceptions of a mother who is overly intrusive.

Ambivalent attachment and depressive symptoms: The role of romantic and parent-chid relationships

In recent years, an increasing amount of attention has been devoted to investigating the interpersonal origins of depression and depressive symptoms. Guided by attachment theory and interpersonal models of depression, we describe a diathesis-stress model that has guided our research on how romantic attachment orientations (or styles) are associated with depressive symptomatology. The model presented in this article suggests that, when anxious-ambivalent people experience stressful events, they display specific perceptual and behavioral reactions that lead to depressive symptoms. Studies that provide empirical support for parts of the model are discussed. In addition to describing the psychological processes that might exacerbate depressive symptoms in highly ambivalent individuals, the model also identifies novel â??pathwaysâ? to depression and briefly introduces new theoretical conceptsâ??the constructs of dysfunctional relationship attitudes and relationship deprivation.

Childhood attachment experiences and adulthood cognitive vulnerability: Testing state dependence and social desirability hypotheses

Childhood attachment experiences correlate with personality and cognitive factors associated with vulnerability to depression. The majority of the research in this area, however, relies on self-report measures which may be influenced by mood state and individual differences in social desirability. The present study examines whether mood and social desirability confound the association between attachment experience and cognitive vulnerability in a sample of clinically depressed adults. Regression analyses revealed a strong link between the two domains that is almost entirely independent of mood state and social desirability. The findings suggest that the association between early interpersonal experience and dysfunctional cognitive processes can not be attributed to current depression or willingness to present oneself in an unfavorable light. Limitations and clinical implications of the results and future directions are discussed.

Point-counterpoint: Two views on traumatic memories and Posttraumatic Stress Disorder

Recent books by Brewin (2003) and McNally (2003b) each reviewed the empirical literature on traumatic memories and posttraumatic stress disorder (PTSD). Although these authors reached similar conclusions on several topics, they differed on a number of important and controversial issues. In this article, Drs. Brewin and McNally are interviewed on these issues, and asked to comment on one anotherâ??s conclusions. Issues discussed include the nature of traumatic events and traumatic stress responses, the problem of malingering in PTSD research, the relative merits of contemporary cognitive models of PTSD, the issues of whether body memories and satanic cult abuse are genuine phenomena, and the question of whether memories can be repressed and later recovered. Implications for the assessment and treatment of PTSD are also discussed. The arguments for and against the various opinions provide fertile ground for stimulating further research into these controversial topics.

Stability and Change of Sociotropy and Autonomy Subscales in Cognitive Therapy of Depression

Sociotropy and autonomy have been demonstrated to be a diathesis for depression as well as predictors of treatment outcome. There are few studies, however, that have investigated whether these vulnerability factors change with cognitive therapy (CT) and are associated with outcome in CT. Also, it appears that the autonomy construct may have both positive and negative content and it is important to examine these two aspects of autonomy in treatment. In this study, depressed outpatients (N = 149) were followed from intake to the 12th session of CT. The treatment outcome variables included depression (BDI), hopelessness (BHS), and sociotropy and autonomy (SAS scale). Using a repeated measures analysis, depression symptoms and hopelessness decreased significantly over time. Both subscales of sociotropy, Preference For Affiliation and Fear of Criticism and Rejection, were positively associated with depression at intake, and decreased significantly over time in those who responded to treatment. However, Independent Goal Attainment, one subscale of autonomy, increased significantly over sessions and was associated with treatment response. The second subscale of autonomy, Sensitivity to Others' Control, demonstrated no change. The results suggest that Independent Goal Attainment may be an indicator of psychological health. Implications for future research using the SAS and its subscales in treatment and vulnerability research are described.

Negative Cognitions Predict the Course of Bipolar Depression, Not Mania

Cognitive interventions for bipolar disorder have received increased attention, but very few prospective studies have focused on whether cognitive variables predict the course of bipolar disorder. Available studies have yielded conflicting results concerning the effects of negative cognitions on mania. In this study, 60 individuals with Bipolar I disorder completed monthly symptom severity interviews. At a six-month follow-up, they completed the Dysfunctional Attitudes Scale, the Negative Automatic Thoughts Questionnaire, and the Positive Automatic Thoughts Questionnaire. Participants then completed monthly symptom severity interviews for another six months. Cognitive scales were correlated with current depression and predicted increases in depression over time, but were not related to mania. Although results do not support negative cognitions as a predictor of mania, they do provide support for the increasingly common use of cognitive interventions to treat bipolar depression.

Developmental Antecedents of Cognitive Vulnerability to Depression: Review of Findings from the Cognitive Vulnerability to Depression Project

In this article, we review findings from the Temple - Wisconsin Cognitive Vulnerability to Depression (CVD) Project (Alloy & Abramson, 1999) regarding potential developmental antecedents of cognitive vulnerability to depression after first briefly summarizing the evidence from the project that negative cognitive styles, information processing, and rumination do, in fact, provide vulnerability to depression. Based on the project findings, we suggest that a continuum of negative emotional feedback, ranging from low emotional warmth/ acceptance and negative inferential feedback at the milder end to emotional abuse at the more severe end, may play an important role in the development of cognitive vulnerability to depression and depression itself.

Cognitive Theory and Therapy of Schizophrenia: Introduction to the Special Issue
Neil A. Rector

Cognitive Therapy for Delusions in Schizophrenia: Models, Benefits, and New Approaches

The main purpose of the review is to demonstrate how cognitive models of psychosis translate into cognitive behavioral approaches for intervening with psychotic symptoms in schizophrenia. Several cognitive behavioral factors which play a role in the maintenance and possibly formation of delusional beliefs are discussed, including, attentional bias to threat, â??data gatheringâ? deficits, dysfunctional metacognition, and safety behaviors. Strategies for engagement, problem formulation, and //psychoeducation with deluded patients are described. Cognitive behavioral interventions are presented, specifically, cognitive restructuring, behavioral experiments, and coping skills training. Challenges to conducting CBT with delusions in schizophrenia are reviewed, accordingly novel cognitive therapies, which address these challenges are presented.

Should CBT target the Social Impairments associated with Schizophrenia?

Adjunctive Cognitive Behavior Therapy (CBT) has been found to reduce the impact of symptoms among individuals with schizophrenia, however CBT has not been used to address the social deficits in this clinical population. The current article elaborates the rationale for targeting social functioning with CBT. These reasons include the following: 1) Social dysfunction is a core feature of schizophrenia that is not directly improved with medication; 2) Improved social functioning is a treatment goal of many patients with schizophrenia, and thus treatments designed to improve social functioning may increase treatment motivation and reduce attrition; 3) Adaptive social functioning is a critical component of mental and physical health, and; 4) Social dysfunction appears to be responsive to psychosocial intervention. This article concludes with a description of Functional Cognitive Behavior Therapy (fCBT), a CBT intervention that has been developed with enhanced focus on social impairments.

Group Cognitive-Behavioral Social Skills Training for Older Outpatients with Chronic Schizophrenia

The number of older patients with schizophrenia is increasing rapidly. There is significant need for empirically validated psychotherapy interventions for these patients. Cognitive behavioral and social skills training interventions have been shown to improve outcomes for younger patients with schizophrenia, but have not been studied in older patients. This paper describes a group intervention for older patients with schizophrenia, cognitive-behavioral social skills training (CBSST), which we are currently studying in a randomized controlled clinical trial. CBSST teaches cognitive-behavioral coping techniques, social functioning skills, problem solving and compensatory aids for neurocognitive impairments. We highlight special issues and specific techniques relevant to working with older patients, and discuss the costs and benefits of using a group, rather than individual approach with this population. To illustrate the approach, two case examples with outcome data are presented.

Update on Cognitive Behavioral Psychotherapy for Schizophrenia: Review of Recent Studies

Cognitive behavioral psychotherapy (CBT) for schizophrenia has been the focus of clinical trials. This article reviews 17 recent studies including five from the United States or Canada. CBT interventions vary by the patient group to whom they are provided. Both individual and group CBT therapies have been developed, some of which have been combined with other psychosocial treatments. There is inconsistency among the study results, but evidence is strongest for the benefit to outpatients who have residual symptoms including hallucinations, delusions, or negative symptoms. Methodological issues include the type of comparison group used, the adequacy of the sample size, and patient attrition. Future investigations of CBT would be improved by a greater standardization of study procedures and by stratifying patients according to clinical characteristics in order to better understand which patients are most likely to benefit.

Cognitive Conceptualization of the Negative Symptoms of Schizophrenia

Cognitive therapy for the treatment of the negative symptoms of schizophrenia is in its infancy. Presented here is an outline of the conceptualization, assessment and treatment of these disabling features of schizophrenia. Examination of possible secondary causes of the negative symptoms, including causes involving dysfunctional attitudes, is followed by a framing of primary negative symptoms in terms of the cognitive model of the influence of thoughts on emotion and behavior. Physiological models of the negative syndrome are incorporated into this cognitive framework. Unique features in the cognitive assessment and treatment of the negative symptoms are outlined. Clinical examples of clients with negative symptoms are provided.

Cognitive Therapy for Auditory Hallucinations in Schizophrenia

Cognitive Therapy has established its efficacy in the United Kingdom as a companion therapy, along with medication, in the treatment of schizophrenia. Randomized controlled trials have been conducted in the UK, showing improvement in both positive and negative symptoms of schizophrenia. Yet less work has been done, testing and implementing Cognitive Therapy for schizophrenia in North America. This article describes the applications of Cognitive Therapy as a treatment for auditory hallucinations, primarily voices. Cognitive Therapy for voices is predicated on the assumption that much of the distress and disability associated with hearing voices is due to the patientâ??s delusional interpretations of voices. The development of a cognitive therapy case conceptualization will be described, as will specific techniques for managing voices and secondary delusions. The objective of treatment is that of increasing the cognitive and behavioral repertoire available to voice hearers, not only to reduce distress, but to increase options for living a meaningful life.

A Cognitive Model of Schizophrenia

The investigation of the cognitive factors in psychosis is still at a relatively early stage of development and has been more or less obscured by the mass of neuro-anatomical, neuro-cognitive, genetic, and pharmacological studies. Despite the relatively low profile of the psychological approaches (especially of the cognitive factors) in psychosis, steady progress has been made as indicated by the papers in this issue. Various researchers such as Richard Bentall (2003) have steadfastly pursued studies for over two decades -- in the face of the dominant biological orientation in the field. The papers in this issue are important for at least two major reasons. First, these papers demonstrate that, despite a common notion that psychotic symptoms are beyond comprehension, they are understandable within the framework of what is known about human nature, generally, and clinical disorders such as depression and anxiety, specifically. These papers demonstrate that the same clinical and research strategies used in exploring the structure of the non-psychotic disorders can be utilized in understanding psychosis. Thus, they have established commonalities extending from the psychological aberrations in normal behavior to the more pronounced distortions in the nonpsychotic disorders to the extreme deviations in psychosis. This approach has had a humanizing influence on the way we see patients with psychosis: We view these patients as similar to the rest of us, struggling with the same kinds of problems and experiencing the same types of distress -- albeit that because of particular vulnerabilities they have psychological experiences that the rest of us experience rarely or only under severe stress. And these experiences in patients are far more devastating then the occasional mental lapses in the general population.

History and Happenstance: How Motivational Interviewing Got Its Start

Examining the intellectual roots of motivational interviewing, as well as the sometimes surprising events that led to its development, can be useful as a context for framing questions about the importance and rationale of the various elements of this clinical method. The origin of clinical components in motivational interviewing, such as empathy and the emphasis on client language, is explored as well as personal collaborations that led to the growth of this approach. Exploration of this developmental path may prove especially important as hypotheses about causal mechanisms of motivational interviewing are developed.

Talking Oneself into Change: Motivational Interviewing, Stages of Change, and Therapeutic Process

Motivational interviewing (MI) is a directive, person-centered clinical method for helping clients resolve ambivalence and move ahead with change. It can be applied as a preparation for treatment, a freestanding brief intervention, an enduring clinical style, or a fallback approach when motivational obstacles are encountered. A psycholinguistic theory is emerging to account for the efficacy of MI that has been demonstrated in numerous clinical trials. For cognitive therapists, MI provides an evidence-based alternative to direct disputation of client cognitions.

The Emerging Evidence Base for Motivational Interviewing: A Meta-Analytic and Qualitative Inquiry

This article offers a meta-analytic, qualitative, and process review of the empirical literature for adaptations of motivational interviewing (AMIs), a promising approach to treating problem behaviors. AMIs are equivalent to other active treatments and yield moderate effects (from 0.35 to 0.56) compared to no-treatment/placebo for problems involving alcohol, drugs, and diet & exercise. Results do not support the efficacy of AMIs for smoking or HIV-risk behaviors. Conclusions regarding the mechanisms of action for AMIs are limited by methodological problems: confounding motivational interviewing with feedback, unclear definitions of the AMI interventions used, difficulties in therapist training, and limited use of treatment integrity rating scales. Extant research suggests that AMIs are equivalent in efficacy to and briefer than Cognitive Behavioral Skills Training (CBST) approaches. Since AMIs focus on readiness to change while CBST targets the change process, AMIs may be useful as preludes or additions to CBST.

How Does Motivational Interviewing Work? What Client Talk Reveals

A psycholinguistic account of motivational interviewing (MI) is proposed. Critical to this view is the assumption that therapists and clients are natural language users engaged in a constructive conversation that reveals and augments relevant information about the status of future change in a clientâ??s substance abuse. The role of client speech acts-- most notably, verbal commitments--during MI is highlighted. How commitments can be signaled in client speech or gestures is discussed. How these commitment signals can inform therapeutic process and subsequent behavioral outcome is then put forth. Using natural language as a measure, a MI process model is presented that not only posits a mediational role for client commitment in relating underlying factors of desire, ability (self-efficacy), need, and reasons to behavior, but also a pivotal role as a need-satisfying enabler of a social-cognitive mechanism for personal change.

Integrating Motivational Interviewing and Cognitive Behavioral Therapy in The Treatment of Depression and Anxiety

Many clients engaging in Cognitive Behavioral Therapy (CBT) for depression and anxiety are ambivalent about change, and about taking necessary actions to bring about change such as exposure or behavioral activation exercises. Given the focus of Motivational Interviewing (MI) on enhancing readiness for change, it is of great interest to investigate applications of MI to prevalent disorders such as depression and anxiety. After exploring the rationale for integrating Motivational Interviewing with CBT for these disorders, we outline unique features of MI which may render it a useful complement to CBT, such as it's focus on resolving ambivalence for change and specific strategies for responding to resistance. We suggest several possible ways in which MI may be combined with CBT. Finally, we discuss our clinical experience with adapting MI to the treatment of depression and anxiety, including case illustrations of each, and discuss some of the unique issues arising in generalizing MI for use with these populations

Expanding the Cognitive Therapy Model: Imagery, Mediation, and Hypnosis

This article describes various types of imagery-based interventions, including meditation, variations of imagery, and hypnosis. Comparisons and contrasts are made among the different techniques developed over the years and example of each are given. The techniques are conceptually based on a model of individual differences in hypnotic ability or susceptibility. Implications for therapeutic practice are discussed.

Clinical Use of the Looming Vulnerability Construct for Performance Anxiety in a Dance Recital

Several recent social phobia models (e.g., Rapee & Heimberg, 1997; Clark & Wells, 1995) share the assumption that sensitivity to the social evaluative context is produced by the socially anxious personâ??s generation of distorted mental images. These distorted images occur in the form of an external â??observerâ? perspective in terms of how the person imagines being perceived by others. The starting point for the model of looming vulnerability (Riskind, 1997; Riskind, Williams, Gessner, Chrosniak, & Cortina, 2000) is that anxiety is generated not just by static images of such a dreadful moment caught in stop motion (e.g., of being negatively viewed by others), but by the perception that the threat is rapidly advancing and unfolding such that it is increasing in danger. The present case study illustrates the potential utility of this â??looming vulnerabilityâ? conceptualization for treating a case of severe social performance anxiety in a young woman facing an upcoming dance recital.