Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. EXPLANATORY STYLE AND DEPRESSION: THE ROLE OF ACTIVITY A thesis presented in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Albany, New Zealand. Rachel Helen Findlay 2011 ii Dedicated to my parents Howard Anthony and Sheila Elizabeth Findlay For your continual love and support And to my late grandmother Lily Irene Findlay (Erb) For teaching me that “Every little bit helps…” iii Abstract Learned helplessness theory and its subsequent reformulation propose that a pessimistic explanatory style renders an individual vulnerable to depression. A large body of literature has supported this association within various samples and utilising a range of methodologies. No prior study has explored explanatory style and depression among a New Zealand sample of clinically depressed adults. Furthermore, no prior research has examined the role of activity level or activity type in relation to these variables. Given the importance of behavioural activation in recovery from depression, Study 1 aimed to bridge this gap. The sample consisted of 29 adult clients diagnosed with Major Depressive Disorder (MDD) and receiving a 20 session protocol of Cognitive Behaviour Therapy (CBT) as part of The Depression Study; a treatment outcome study conducted at Massey University, Albany, Auckland, New Zealand. Data were derived from intake assessment scores for explanatory style and depression severity, as measured via the Attributional Style Questionnaire (ASQ) and Beck Depression Inventory–Second Edition (BDI-II) respectively. Data were also derived from several activity level and activity type indices formulated for Study 1 by the use of information contained within activity charts; a tool used for a between-session task (homework) conducted early in CBT. Study 1 supported an association between a pessimistic explanatory style and depression severity and provisional support was found for the proposed model of the current project, implicating the role of activity among interactions between explanatory style and depression. In collecting data for Study 1 it became apparent that an adaptation to the activity chart may yield greater information particularly with regard to activity type, such as the extent to which social interaction occurred. Study 2 of the current research project aimed to compare the original activity chart with the adapted chart, by grouping The Depression Study clients according to whether they completed the original (n = 15) or the adapted (n = 8) activity chart, and comparing the data obtained. Mann-Whitney U tests confirmed that the adapted chart was more successful in collecting information regarding social interaction and ratings for mastery and pleasure. It is suggested that the adapted chart could be more beneficial in contrast to the chart typically used in CBT to date; this advantage could extend across both research and clinical settings for the examination of client activity. iv Acknowledgements I would first like to thank my primary supervisor, Dr. Jennifer Stillman, who has consistently made herself available throughout the entire time periods during which I worked on my MSc and DClinPsych theses. I would also like to thank my second supervisor, Associate Professor Paul Merrick, for all of his support and useful guidance in relation to my DClinPsych thesis and my clinical training in general. I feel fortunate to have had such approachable supervisors with a wealth of knowledge to share. I am grateful to Dr. Nik Kazantzis, for his supervision during the earlier stages of this research, and for the added CBT training, experience, and clinical supervision that I gained as a member of The Depression Study. I would also like to thank Robyn Vertongen, who was my clinical supervisor throughout this involvement. I would like to extend my appreciation to Associate Professor Mandy Morgan, for her understanding and support in recent months. I would also like to thank Associate Professor John Spicer, for his recent advice and guidance. I am grateful for the fellow therapists of The Depression Study who I shared many ideas and experiences with, in particular Carol Osborne and Jeanne Daniels. I would also like to thank Margo Munro, a consistently helpful and valuable member of the research team. My utmost gratitude is extended to the participants of The Depression Study, for being willing to participate, complete numerous questionnaires, and share their experiences with their therapists, thus allowing the research to happen. I am very appreciative of all the family, friends, and colleagues who have helped me in some way during my time conducting this research. A special thank you is extended to my partner, Lee Tomkins, for his unwavering support at a time when it was most needed. I am also very grateful to one of my dearest friends, Claire Toomey, for always understanding and knowing how, and when, to best support me. I would like to thank Bevan and Rachael Thomson, for helping me with printing, having me to stay, and for always listening. Finally, I would like to thank my previous manager, Alison Kirkpatrick, for her selfless kindness and understanding. v Table of Contents Abstract .................................................................................................... iii Acknowledgements .................................................................................. iv List of Tables ............................................................................................ x List of Figures .......................................................................................... xi LITERATURE REVIEW ........................................................................ 1 INTRODUCTION AND OVERVIEW ..................................................................... 1 CHAPTER 1: Definition, History, and Theories of Explanatory Style ................ 2 Major Depressive Disorder: Definition, prevalence, and assessment ....................... 2 The learned helplessness theory ................................................................................ 4 The reformulated learned helplessness theory .......................................................... 7 Terminology of explanatory style ............................................................................. 8 Optimism and pessimism: Definition and research approaches ............................... 8 Related constructs ................................................................................................... 11 Summary ................................................................................................................. 12 CHAPTER 2: Explanatory Style and Depression; Empirical Support .............. 13 Empirical support with child and adolescent populations ...................................... 14 Predictions of the reformulated learned helplessness theory ........................................ 14 The development of explanatory style ............................................................................ 17 Empirical support with tertiary student populations ............................................... 17 Predictions of the original learned helplessness theory ................................................ 18 Predictions of the reformulated learned helplessness theory ........................................ 18 Empirical support with adult populations ............................................................... 19 Predictions of the original learned helplessness theory ................................................ 19 Predictions of the reformulated learned helplessness theory ........................................ 21 vi CHAPTER 3: Explanatory Style Research; Useful Considerations ................... 28 Explanatory style for negative versus positive events ............................................ 28 Alternative explanations ......................................................................................... 30 Methodological limitations in explanatory style research ...................................... 32 Design issues in published research ............................................................................... 32 Categorisation of depression .......................................................................................... 33 Measurement of causal attributions or explanatory style .............................................. 34 Measurement of life events ............................................................................................. 36 Potential confounding factors ........................................................................................ 36 Overall conclusions of explanatory style research .................................................. 37 CHAPTER 4: Cognitive Behaviour Therapy for Depression .............................. 41 The common objective of cognitive approaches..................................................... 41 Cognitive therapies versus cognitive behaviour therapies ...................................... 41 Beck’s Cognitive Therapy ...................................................................................... 43 History of development ................................................................................................... 43 Overview of the approach .............................................................................................. 44 Cognitive theory and practice ........................................................................................ 45 Summary ................................................................................................................. 48 CHAPTER 5: The History and Value of Behavioural Activation ....................... 49 Behavioural interventions in CBT .......................................................................... 49 Definition, history, and theories of behavioural activation ..................................... 49 Behavioural activation as a component of CBT for depression.............................. 52 Empirical support for behavioural activation.......................................................... 53 Comparisons of cognitive behaviour and behavioural therapies ................................... 53 Summary and critique of the component analyses ......................................................... 56 Follow-up data of the component analyses: Relapse prevention ................................... 58 Summary ................................................................................................................. 60 CHAPTER 6: Behavioural Activation in the Context of Activity Type ............. 61 Engagement in pleasant activities ........................................................................... 61 Engagement in mastery-inducing activities ............................................................ 62 Client beliefs and individual differences ................................................................ 63 Engagement in social interaction ............................................................................ 64 vii Induced mood and activity type choices ................................................................. 65 Quantity versus quality in the efficacy of behavioural activation .......................... 66 Summary ................................................................................................................. 68 CHAPTER 7: Cognitive Mechanisms of Change.................................................. 69 Empirical support for cognitive mechanisms of change ......................................... 69 Explanatory style change via CBT .......................................................................... 74 Mechanisms of change: Important considerations .................................................. 76 Summary ................................................................................................................. 78 THE PRESENT STUDIES .................................................................... 79 CHAPTER 8: Study 1 Aims and Rationale ........................................................... 79 Overall aim and rationale ........................................................................................ 79 Proposed framework ............................................................................................... 80 Compatibility of theories ........................................................................................ 81 Specific aims and rationale ..................................................................................... 84 Path 1 in the model ........................................................................................................ 84 Path 2 in the model ........................................................................................................ 85 Path 3 in the model ........................................................................................................ 86 Paths 1 and 2 in the model ............................................................................................. 88 Summary ................................................................................................................. 92 CHAPTER 9: Study 1 Method ............................................................................... 93 Overview of data collection .................................................................................... 93 Therapist training and monitoring ........................................................................... 93 Participants .............................................................................................................. 95 Recruitment and screening ............................................................................................ 95 Description of sample .................................................................................................... 96 Treatment ................................................................................................................ 98 Data collection ........................................................................................................ 99 Measurement instruments ....................................................................................... 99 Explanatory style ........................................................................................................... 99 Depression severity ...................................................................................................... 103 The use of activity charts in clinical practice ........................................................ 105 viii The use of activity charts in the present study ...................................................... 106 The measurement of activity level ........................................................................ 108 Time in activity (Duration) ........................................................................................... 108 Range of activities (Variety) ......................................................................................... 109 Frequency of activity changes (Frequency) ................................................................. 110 Example of activity level indices .................................................................................. 111 The measurement of activity type ......................................................................... 112 Active and passive ........................................................................................................ 112 Social and nonsocial..................................................................................................... 112 Mastery and pleasure frequency .................................................................................. 113 Mastery and pleasure magnitude ................................................................................. 113 Summary of methodology ..................................................................................... 114 CHAPTER 10: Study 1 Results ............................................................................ 115 Overview of data treatment ................................................................................... 115 Preliminary analyses: Detection of outliers .......................................................... 116 Data analysis approach.......................................................................................... 118 Results ................................................................................................................... 120 Aim 1 ............................................................................................................................. 120 Aim 2 ............................................................................................................................. 123 Aim 3 ............................................................................................................................. 125 Aim 4 ............................................................................................................................. 127 CHAPTER 11: Study 2 .......................................................................................... 134 Background to the present study ........................................................................... 134 Overview ....................................................................................................................... 134 Rationale, aim, and hypotheses .................................................................................... 134 Method .................................................................................................................. 136 Study variables ............................................................................................................. 137 Results and preliminary discussion ....................................................................... 138 Social interaction.......................................................................................................... 138 Activity chart completion quality .................................................................................. 138 DISCUSSION ........................................................................................ 140 CHAPTER 12: Discussion of Specific Findings .................................................. 140 ix Study 1: Findings and tentative conclusions ......................................................... 140 Path 1 ........................................................................................................................... 141 Path 2 ........................................................................................................................... 142 Paths 1 and 2 ............................................................................................................... 143 Path 3 ........................................................................................................................... 147 Differential associations across indices ................................................................ 148 Activity level indices: Explanatory style versus depression severity ........................... 148 Explanatory style indices: Negative versus positive events ......................................... 150 Summary and conclusions of Study 1 findings ..................................................... 152 Study 2: Findings and conclusions ........................................................................ 153 CHAPTER 13: General Discussion ...................................................................... 156 Conceptual overlap and alternative explanations .................................................. 156 Limitations of the research .................................................................................... 160 Implications for mental health .............................................................................. 167 Implications for clinical practice ................................................................................. 167 The importance of continued clinical research ............................................................ 170 Suggestions for future research ............................................................................. 171 Concluding comments ........................................................................................... 175 REFERENCES ..................................................................................... 177 APPENDICES ...................................................................................... 204 APPENDIX A: Original Activity Chart............................................................... 205 APPENDIX B: Adapted Activity Chart............................................................... 208 APPENDIX C: Variable Descriptions.................................................................. 211 APPENDIX D: Descriptive Statistics of Study 1 Variables/Indices .................. 212 APPENDIX E: Summary Table of Significant Study 1 Correlations ............... 213 x List of Tables Table 1 Demographic characteristics of The Depression Study participants………………………………………..……………... 97 Table 2 Intercorrelations (r) between ASQ subscales in the present study and those of Hjelle et al. (1996) and Peterson et al. (1982)…....... 102 Table 3 Pearson’s product-moment and Spearman’s Rho correlation coefficients and significance values, between activity level indices and explanatory style indices…………………….……... 121 Table 4 Pearson’s product-moment and Spearman’s Rho correlation coefficients and significance values, between depression severity and activity level indices……………………………...... 123 Table 5 Pearson’s product-moment and Spearman’s Rho correlation coefficients and significance values, between depression severity and explanatory style indices………..…………………. 125 Table 6 Pearson’s product-moment and Spearman’s Rho correlation coefficients and significance values, between activity type variables and explanatory style indices………..………………... 128 Table 7 Pearson’s product-moment and Spearman’s Rho correlation coefficients and significance values, between depression severity and activity type variables…………………………….... 132 Table 8 Median recording percentages and Mann-Whitney U test statistics and exact significance values as a function of activity chart completed………………………………………………….. 139 xi List of Figures Figure 1 The proposed model; the reciprocal relationship between explanatory style, activity, and depression severity…….………. 81 Figure 2 Example of Beck’s Five Part Model, displaying the interrelationships between cognitions, behaviour, emotions, and physiology……………………………………………………….. 83 Figure 3 Example segment of a typical activity chart, with one cell completed with an activity, mood rating, and mastery rating, for illustrative purposes……………………………………………... 105 Figure 4 Example of a hypothetical activity chart, partially completed with example activities, for illustrative purposes……………….. 111 Figure 5 Scatterplot showing the association between the Duration activity level index and the Positive Events explanatory style index…………………………………………………………….. 122 Figure 6 Scatterplot showing the association between the Duration activity level index and the Overall Composite explanatory style index…………………………………………………………….. 122 Figure 7 Scatterplot showing the association between the Variety activity level index and depression severity……………………….…….. 124 Figure 8 Scatterplot showing the association between the Frequency activity level index and depression severity…………….………. 124 Figure 9 Scatterplot showing the association between the Negative Events explanatory style index and depression severity……………..….. 126 xii Figure 10 Scatterplot showing the association between the Positive Events explanatory style index and depression severity…………..…….. 126 Figure 11 Scatterplot showing the association between the Overall Composite explanatory style index and depression severity……. 127 Figure 12 Scatterplot showing the association between the Pleasure Frequency activity type variable and the Positive Events explanatory style index………………………………………….. 129 Figure 13 Scatterplot showing the association between the Mastery Magnitude activity type variable and the Positive Events explanatory style index………………………………………….. 130 Figure 14 Scatterplot showing the association between the Pleasure Magnitude activity type variable and the Positive Events explanatory style index………………………………………….. 130 Figure 15 Scatterplot showing the association between the Pleasure Magnitude activity type variable and the Overall Composite explanatory style index………………………………………….. 131 Figure 16 Scatterplot showing the association between the Pleasure Magnitude activity type variable and depression severity……..... 132