Advances in
Cognitive - Behavioral
Research and Therapy
Volume 5
Edited by
PHILIP C. KENDALL
Department of Psychology
Temple University
Philadelphia, Pennsylvania
1986
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Preface
Cognitive-behavioral approaches to assessment and intervention
with adults and children have received widespread acceptance. In addition to this expanding acceptance, there continue to be increases in
the quality and quantity of research and applications pertinent to the
integration of such topics as cognition and behavior, affect, social systems, and development. The size of the field requires an outlet for
authoritative reviews, critical commentaries, and theoretical treatises, as well as more speculative analysis.
Advances in Cognitive - Behavioral Research and Therapy is broadly
conceived to include a diversity of topics. For example, systematic exploration of assessment issues, theoretical analyses, treatment strategies
for distinct clinical disorders, basic studies in psychology and psychopathology, and advanced research methodologies are a few of the topics
appropriate for inclusion. Drawing on the developments in the study of
cognition, behavior therapy, development, learning, personality, and
social interaction, and occasionally including dialogues on pertinent
issues, this serial publication draws together the advances in diverse
areas related to cognitive-behavioral research and application. All
contributions are prepared with the academic researcher and practicing
clinician in mind. Advances in Cognitive -Behavioral Research and
Therapy, a serial publication, is not intended to be only a collection of
literature reviews, nor is it designed to serve solely as a display of treatment successes. Rather, each volume contains a collection of articles
that deal with a sample of the numerous content areas that are of interest to researchers and clinicians struggling with the interplay of cognition and behavior. There is not a single theme or mold to each volume.
Rather, each contribution stands by itself. Most important, perhaps,
contributors are encouraged to develop their thinking and present these
advances in their contributions.
T h e contributions of research and applied psychologists contained in
Volume 5 include assessment, treatment, and theoretical papers.
ix
χ
Preface
Schwartz and Garamoni provide an integrative and stimulating analysis
and review of the internal dialogue. In addition, they offer a model for
the understanding of the balance between positive and negative thinking and adjustment. In the next chapters, by S m i t h - A l l r e d and Marzillier, respectively, two of the seminal approaches within cognitive behavioral therapy are examined. Ellis' rational emotive model is
considered by Smith and Allred, with a special focus on empirical evaluations and the methods for assessment of rationality. With a greater
focus on treatment, Marzillier addresses Beck's cognitive-behavioral
methods for depression that are receiving wide application and evaluation. In each chapter, the author(s) provide(s) a current consideration of
the seminal contributions. T h e topic of depression is also addressed by
Kuiper and Olinger as they examine the notion of self-schema, the
interactive role of dysfunctional cognitions and negative life events, and
the self-worth contingency model for understanding the development
of depressive disorders. Safran and Greenberg then provide an informative analysis of psychotherapy from both a cognitive and affective viewpoint. Models of information processing are examined as they relate to
the process of change, and the roles of emotions within this change
process are considered. T h e role of causal attributions, their antecedent
and consequents, their role in health and illness behaviors, and related
implications for research and treatment are then provided in a theoretically rich and detailed review by Michela and Wood. In the final chapter, by Azar and Twentyman, the important topic of child abuse is
examined from a cognitive-behavioral perspective. Issues of maltreatment and stress and procedures for assessment and treatment are considered. T h e negative effects of inordinate expectations is highlighted.
I am grateful to each of the authors for being a part of this venture and
to the staff of Academic Press for their expertise and support. I also wish
to recognize the competent aid of the staff of my home institution,
Temple University, especially Elaine Gatsoulas, and the highly valued
support of my wife, Sue.
Philip C. Kendall
A Structural Model of Positive and
Negative States of Mind: Asymmetry
in the Internal Dialogue
ROBERT M. SCHWARTZ
Department of Behavioral Science and
Western Psychiatric institute and CJinic
University of Pittsburgh
Pittsburgh, Pennsylvania 15261
GREGORY L. GARAMONI
Department of Psychology
University of Pittsburgh
Pittsburgh, Pennsylvania 15260
I. Introduction
II. Conceptions of Polarity
A. From Yang and Yin to the Semantic Differential. . .
B. Polarity in the Internal Dialogue
C. Conceptual and Definitional Issues
D. Bidimensional Assessment
III. The Golden Section Hypothesis
A. The Golden Section
B. Theoretical Explanations
IV. States of Mind Model
A. Self-Statements and the Internal Dialogue
B. Overview of States of Mind Model
C. States of Mind Defined
V. Empirical Evaluation of the Model
A. Set Points and Ranges
B. Validity Issues
VI. Directions for Clinical Research and Practice
A. Implications for Assessment
B. Research and Clinical Issues
VII. Conclusion
References
2
4
5
6
7
10
11
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21
30
40
43
45
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47
54
55
1
ADVANCES IN COGNITIVE-BEHAVIORAL RESEARCH
AND THERAPY, VOLUME 5
Copyright ©1986 by Academic Press. Inc.
All rights of reproduction in any form reserved.
2
Robert M. Schwartz and Gregory L. Garamoni
The equal part may be described as a mean between too much and too little. By the
mean of the thing I understand a point equidistant from the extremes. . . . The man
who knows his business avoids both too much and too little. It is the mean he seeks
and adopts. (Aristotle)
Life is asymmetric. (Guidano & Liotti, 1983)
I. INTRODUCTION
Philosophers, artists, and scientists throughout history have adopted
the ancient Greek idea of symmetry to "comprehend and create order,
beauty, and perfection" (Weyl, 1952, p. 5). In contrast to this veneration
of symmetry, asymmetry was typically viewed as secondary and even
disturbing: A striking example is the perturbing asymmetry or irreversibility of time ("time's arrow") that underlies the inexorable movement of the universe toward entropy (Bochner, 1973). Yet modern scientific research has revealed benign and intriguing asymmetries in
cerebral hemispheric specialization (Kinsbourne, 1978), facial expression (Rinn, 1984), and neurochemical function (Tucker & Williamson,
1984). It is therefore less surprising that functional asymmetries have
been discovered in recent cognitive-behavioral research (Kendall &
Hollon, 1981; Safran, 1982; Schwartz, 1986; Schwartz & Gottman, 1976).
Studies that include a bidimensional assessment of cognition consistently reveal an asymmetry between positive and negative thoughts,
whereby the negative dimension has greater functional impact than the
positive on psychological adjustment, coping, and the process of therapeutic change. For example, Schwartz and Gottman (1976) found that
although functionally positive and negative self-statements both related
to assertiveness, the effect was stronger for the negative dimension. In a
study of coping with medical stress, Kendall, Williams, Pechacek, Graham, Shisslak, and Herzoff (1979) reported that only negative cognitions
differentiated the effective from the ineffective coper. Finally, several
psychotherapy outcome studies indicated that successful treatment resulted in a decrease in negative thoughts without a corresponding increase in positive thoughts (Derry & Stone, 1979; Mavissakalian, Michelson, Greenwald, Kornblith, & Greenwald, 1983). The discovery of
this functional asymmetry in cognition led Kendall (Kendall, 1982; Kendall & Hollon, 1981) to aptly observe that the "power of nonnegative
thinking" may be more accurate than the familiar, popularized phrase.
Although this asymmetrical pattern is new to cognitive-behavioral
researchers, a related phenomenon called the negativity bias has been
investigated by social psychologists. Considerable evidence supports
the facts that negative information carries more weight than positive in
States of Mind Model
3
impression formation and evaluation of others (Kanouse & Hanson,
1972), that the response to losses is more extreme than the response to
gains (Tversky & Kahneman, 1981), and that negative life events have
greater impact than positive ones (Zautra & Reich, 1983). Thus, the
asymmetry between positive and negative thoughts appears to be a
fundamental and pervasive aspect of human information processing.
How is this phenomenon, which can be called the negative strikingness asymmetry, to be understood? Ironically, it may be the result of a
complementary positivity bias that characterizes human cognition (cf.
Kanouse & Hanson, 1972). Many aspects of information processing are
permeated by a tendency for humans to view things positively. This
positivity bias or "Pollyanna principle" has been documented by over
1000 studies covering areas such as language, expectations, memory,
self-perception, evaluation of others, and thinking (Matlin & Stang,
1978). As Kanouse and Hanson explain, the "negativity biases occur
against a backdrop of perceived bliss — indeed because of it" (p. 56).
Since people view themselves and the world as generally positive, the
less frequent negative cognitions and events have greater information
value and are therefore weighted more heavily: Against a positive background, negative cognitions become more striking figures.
The negative strikingness asymmetry focuses exclusively on the salience of the negative dimension, whereas the Pollyanna principle deals
only with the complementary positive dimension. A more dialectical
formulation that integrates both the positive and negative dimensions
would represent an important conceptual advance. Fortunately, an elegant and quantitatively precise theory and line of experimental research exists that focuses on the balance or harmony between positive
and negative thoughts. This formulation, known as the golden section
hypothesis, holds that "while we construe most events positively, we
attempt to create a harmony between positive and negative events such
that the latter make a maximal contribution to the whole" (Benjafield &
Adams-Webber, 1976, p. 14). This hypothesis — derived from ancient
mathematical calculations traced to Pythagoras and supported by contemporary information-processing theory — holds that there is an optimal balance of positive and negative cognitions that can be quantified
and is presumed to relate to effective psychological functioning. As is
evident, this formulation incorporates the fact that people tend to view
things positively (Pollyanna principle) as well as the consistent finding
that the negative dimension has a greater impact or makes a maximal
contribution to the whole (negative strikingness asymmetry). Beyond
that, the golden section hypothesis maintains that this relationship
holds only when a specific and optimal harmony between positive and
negative cognitions is achieved.
4
Robert M. Schwartz and Gregory L. Garamoni
Incorporating the golden section hypothesis, we have developed a
structural model of positive and negative states of mind (Garamoni &
Schwartz, 1986; Schwartz & Garamoni, 1984, 1986a) that draws upon
principles of information processing, cybernetic self-regulation, and intrapersonal communication (Garner, 1962, 1974; Carver & Scheier,
1 9 8 1 , 1 9 8 3 ; Meichenbaum, 1977). Specifically, the model proposes that
functionally optimal states of mind consist of a precise balance of positive and negative cognitions a n d / o r affects, closely approximating the
golden section proportion. Such asymmetrically balanced cognitive/affective structures proportioned according to the golden section render
negative events and cognitions maximally striking and are therefore
optimally suited for coping with stress (Adams-Webber, 1982; Berlyne,
1971; Rigdon & Epting, 1982; Shalit, 1980). Consequently, any substantial and lasting deviations (in either direction) from the golden section
represent distinct states of mind that are hypothesized to be associated
with various forms of psychopathology. In agreement with Aristotle, the
person who knows his business does avoid both too much and too little.
According to the present model, he accomplishes this by adopting not
the point equidistant between the extremes, but rather the asymmetrical "golden mean."
In sum, the purpose of this article is to (1) demonstrate the heuristic
value of conceptualizing the "internal dialogue" as a dialectical process
based on the fundamental polarity of positive and negative cognitions
(Section II); (2) review the golden section hypothesis and its associated
information-processing properties (Section III); (3) present a rationally
derived and empirically grounded model of states of mind that draws
upon the concept of positive-negative polarity, the golden section hypothesis, information-processing principles, intrapersonal communication concepts, and cybernetic theory (Section IV); (4) evaluate the
extent to which the model fits existing data (Section V); and (5) explore a
number of related research and clinical issues (Section VI).
II. CONCEPTIONS OF POLARITY
Cognitive - behavioral researchers have only recently begun to investigate polarity in the internal dialogue by assessing the positivenegative dimension of thought. Yet the idea of polarity — a structured
balance or organization of two opposing attributes, clashing tendencies,
or contradictory principles — is as old as human thinking about thinking and feeling itself (Meerlo, 1954). Contemporary conceptions of polarity have a rich intellectual heritage, originating in diverse ancient cultures and influencing subsequent developments in philosophy, art, and
science, including psychology.
States of Mind Model
5
A. From Yang and Yin to the Semantic Differential
Eastern and Western cultures have, since their earliest origins, embraced the idea of polarity to comprehend the universe in general and
human nature in particular. T h e ancient Chinese understood harmony
or discord in their world in terms of balance or imbalance in life's
opposing forces, Yang and Yin. T h e ancient Greeks, particularly the
Pythagoreans, similarly held that the universe was designed according
to specific harmonious proportions. Such philosophical conceptions of
polarity have had a ubiquitous influence on the history of ideas, reaching a zenith during the nineteenth century in the formulations of dialectical idealism and materialism.
In science, the idea of polarity has yielded theoretical and empirical
advances in various disciplines, including mathematics (positive and
negative numbers), physics (positive and negative poles), chemistry
(positive and negative ions), and biology (positive and negative neurotransmission). In medicine specifically, the notion of health as a proper
balance of opposites influenced Galen, who formulated the classic
theory of body humors, which was based on the blending of four basic
qualities (hot, cold, dry, moist) in binary combinations. Manifestations
of this view remained dominant until the seventeenth century (Temkin,
1973). In general, health was viewed as balance, harmony, or symmetry
and disease as their disturbance. These ideas presaged contemporary
concepts of homeostasis (Cannon, 1932) and "eustress" (Selye, 1974),
both of which imply that some optimal balance — typically unspecified
— is a necessary condition for physical health.
Psychologists have also conceptualized mental health and other basic
psychological phenomena in terms of a polarity of opposites. William James ( 1 8 9 0 / 1 9 5 0 ) — anticipating current cognitive-behavioral
theories — held that human action could be understood as a joint function of "favorable" and "antagonistic" ideas struggling for dominance
within the mind. Psychodynamic theorists conceptualized normal and
pathological behavior in terms of an interaction and balance between
conflicting polarities (Bleuler, 1914; Erikson, 1 9 5 0 / 1 9 6 3 ; Freud,
1 9 2 0 / 1 9 5 5 ; Jung, 1964; Lewin, 1935; see also Werner, 1957). Biological
psychologists have conducted research on the pathophysiology of various disorders based on presumed functional imbalances in the polarities of neurotransmission (e.g., Klein, 1974).
Basic psychological research closely tied to cognitive-behavioral
theory has successfully employed the positive - negative dimension as
well. Experimental studies on approach-avoidance operationalized
conflicting polarities at the behavioral level (Miller, 1944). Principles of
positive and negative reinforcement have generated an unprecedented
6
Robert M. Schwartz and Gregory L. Garamoni
volume of research on operant learning (Skinner, 1953; Honig, 1966).
Cognitive theories of emotion (Arnold, 1960; Lazarus, 1966) advanced
the hypothesis that positive and negative appraisals are causally related
to affect. And lastly, in psycholinguistics, the positive-negative dimension has been found to explain up to 7 5 % of the variance in semantic
differential studies (Osgood, Suci, & Tannenbaum, 1957).
Β. Polarity in the Internal Dialogue
Given this rich heritage, it follows that the concept of polarity should
play an important role in advancing our understanding of the pathological and therapeutic implications of the internal dialogue. In fact,
cognitive-behavioral theorists have employed a wide array of constructs of polarity to conceptualize cognitive factors in anxiety, stress,
and depression (Abramson, Seligman, & Teasdale, 1978; Beck, 1976;
Ellis, 1962; Kelly, 1955; Meichenbaum, 1977).
These constructs of positive and negative thinking have inspired recent advances in assessment and a growing body of research (Kendall &
Hollon, 1979; Merluzzi, Glass, & Genest, 1981). Measures of "positive
and negative self-statements" have been employed in studies of unassertiveness (e.g., Schwartz & Gottman, 1976), social anxiety (e.g., Glass,
Merluzzi, Biever, & Larson, 1982), and coping with an invasive medical
procedure (Kendall et αϊ., 1979). In a study of test anxiety, Hollandsworth, Glazeski, Kirkland, Jones, and Van Norman (1979) assessed "ontask" and "off-task" self-statements and "positive and negative selfevaluations." In a psychotherapy outcome study, Mavissakalian et αϊ.
(1983) assessed agoraphobics' pre- and posttreatment "coping thoughts"
and "fearful thoughts" during the course of treatment. Stress researchers have investigated the role of "positive and negative appraisals" in mediating affective-physiological responses to stressors
(Lazarus, 1966) and the effects of "desirable" and "undesirable" life
events (Johnson & Sarason, 1979; Kanner, Coyne, Schaefer, & Lazarus,
1981). Depression research has also measured positive and negative
dimensions of self-verbalization (Missel & Sommer, 1983), attributional
style (Abramson et ah, 1978), memory (Clark & Teasdale, 1982), self-reinforcement (Rehm, 1977), and self-schema (Derry & Kuiper, 1981).
The empirical yield from these and other studies demonstrates the
heuristic value of conceptualizing polarity as a fundamental, clinically
relevant aspect of the internal dialogue. Recognizing the fertility of this
construct, Kendall and Hollon (1981) recommended that "the assessment of self-statements should always attempt to include an examination of the valence dimension by providing both positive and negative
items on measures using the endorsement method or coding the re-
States of Mind Model
7
corded/written material into positive and negative categories" (p. 111).
Before the full potential of this approach can be realized, however,
polarity in the internal dialogue must be conceptualized and defined.
C. Conceptual and Definitional Issues
Amid the diverse operationalizations of polarity in cognitivebehavioral research, one can intuitively grasp a family resemblance of
related, yet nonidentical meanings. Knotty conceptual issues arise in
trying to capture an underlying, common definition. However, confounds can be avoided if two basic meanings of the positive-negative
construct are separated: functional impact and evaluative content.
1. Functionally Positive and Negative Cognitions
Cognitive-behavioral theories share the assumption that thoughts
significantly and measureably influence aspects of psychological experience (i.e., cognitive, affective, physiological, motoric, and interpersonal). Theorists may differ on the purported effects of specific types of
cognition, but a unifying mission is to identify their positive and negative effects. Accordingly, several investigators have conceptualized the
positive-negative dichotomy in terms of the functional impact of
thoughts (self-statements) on coping with a situationally specific threat
or problem.
In their study of assertiveness, Schwartz and Gottman (1976) defined
positive self-statements as those that facilitate or "make it easier to
refuse" the request, and negative self-statements as those that inter/ere
or "make it harder to refuse." Examples of assertion-relevant positive
and negative self-statements are, respectively, "I was thinking that I am
perfectly free to say n o " and "I was worried about what the other person
would think of me if I refused." In their study of coping with surgical
stress, Kendall et αϊ. (1979) operationalized the positive-negative dimension in terms of thoughts that would help or hinder coping behavior
of patients undergoing a cardiac catheterization procedure. Relevant
examples of positive and negative self-statements are, respectively,
" T h e procedure could save my life" and " T h e doctor looks too young
and inexperienced." Functional impact thus represents one fundamental aspect of the positive-negative dimension of cognition.
von Wright's (1963) trenchant philosophical analysis of axiological
terms (i.e., those employed in value theory) provides a basis for conceptualizing the functional impact of cognition. His analysis of the application of value terms to behavior implies that the consequences of a
thought determine whether it is functionally positive or negative. Actually, two relations are embedded in this construct: causality and value.
8
Robert M. Schwartz and Gregory L. Garamoni
A given thought is positive or negative depending, first, on whether it
has a causal impact on the good or well-being of an individual, and,
second, on whether these effects are beneficial or harmful. Thus, a
functionally positive cognition is favorably causally relevant to some
desirable outcome, whereas a functionally negative cognition is unfavorably causally relevant. Operationally defined, functionally positive
cognitions increase the probability of some positively evaluated event
a n d / o r decrease the probability of a negatively evaluated event; functionally negative thoughts decrease the probability of a positively evaluated event a n d / o r increase the probability of a negatively evaluated
event.
2. Evaluatively Positive and Negative Cognitions
Evaluative-affective content represents another fundamental aspect
of the positive-negative dimension. Here the focus is on subjectively
defined evaluative or affective meaning, which is usually expressed in
judgments that employ evaluative (e.g., friendly/unfriendly) or affective words (e.g., happy/sad). When someone evaluates something as
good or as bad or verbalizes a pleasant or unpleasant emotion, such
statements may be classified as positive or negative based on the valence
of the predicate content. The criterion for this classification is the expressed, subjective evaluative-affective meaning of the statement, not
its objective impact on the individual's well-being.
Studies of depression have typically assessed cognitions in terms of
evaluative-affective content. For example, Derry and Kuiper (1981)
measured recall for personal adjectives with nondepressed (e.g., amiable) and depressed content (e.g., dismal). Similarly, Missel and Sommer
(1983) assessed self-verbalizations in terms of positive (e.g., "My capability to convince others makes me proud of myself") and negative
content (e.g., "Still, I should have been more convincing"). In both
studies, cognitions were classified as positive or negative based on their
evaluative-affective valence.
3. Function versus Content
Typically, the function and content dimensions are equivalent: Statements that are functionally positive are usually evaluatively positive,
and those that are functionally negative are also evaluatively negative.
In studies of social-evaluative anxiety (Bruch, Haase, & Purcell, 1984;
Glass et al, 1982), the results of factor analyses suggest that the functional and evaluative dimensions of cognition are closely related. Moreover, depression research indicates that evaluatively positive and nega-
States of Mind Model
9
tive cognitions have functionally positive and negative effects,
respectively, on mood.
This correspondence is illustrated by positive and negative self-statements taken from inventories used in research on assertiveness, social
anxiety, and coping with medical stress. A study by Kendall et al. (1979)
indicated that patients who coped poorly with a cardiac catheterization
procedure were more likely to think that "the catheter might break off
and stick into my heart." This type of self-statement expresses a negative evaluation and presumably increases the likelihood of harmful
consequences. Conversely, self-talk is frequently both functionally and
evaluatively positive. For example, while engaging an eligible woman
in conversation, a single man with low social anxiety is likely to say to
himself "she may want to talk to me as much as I want to talk to her"
(Glass et al, 1982). Such evaluatively positive self-statements would
presumably facilitate appropriate social behavior and not have negative
consequences.
However, the potential for confounds exists because functional impact is not always isomorphic with evaluative-affective content. Some
evaluatively negative cognitions appear to have beneficial consequences (Arnkoff & Glass, 1982; Kendall & Hollon, 1981). For example,
Schwartz and Gottman (1976) indicated that an assertive individual,
when confronted with a stranger's request to cut in line at the movies,
would be likely to think "this is an unreasonable request." This evaluatively negative thought would presumably facilitate assertive behavior.
Conversely, some evaluatively positive thoughts may decrease the
probability of a beneficial outcome. Facing the same unreasonable request, a nonassertive person would think "it is always good to be helpful
to other people." This evaluatively positive self-statement would presumably inhibit an assertive response.
Awareness of the difference between the functional impact and the
evaluative-affective content of self-statements may help to avoid potentially costly confounds in future research. This distinction may account for a recent replication failure in a study of nonassertion. In studies that assessed the functional impact of thought ("facilitory and
inhibitory self-statements"), differences between assertives and nonassertives were consistently found (Bruch, 1981; Heimberg, Chiauzzi,
Becker, & Madrazo-Peterson, 1983; Pitcher & Meikle, 1980; Schwartz &
Gottman, 1976). However, the one study (Chiauzzi & Heimberg, 1983)
that assessed evaluative content ("favorable and unfavorable self-statements") failed to find similar group differences. Although this replication failure was attributed to a methodological artifact, possible confounds in the operationalization of polarity cannot be ruled out.
10
Robert M. Schwartz and Gregory L. Garamoni
D. Bidimensional Assessment
In response to the increased attention given to the positive-negative
dichotomy in cognitive-behavioral research, Arnkoff and Glass (1982)
warned that focusing too heavily on this dimension may oversimplify a
considerably more complex picture. Davison, Robins, and Johnson
(1983) also argued that minimal restrictions on categories should be
employed in exploring thought because so little is known about the role
of cognition in psychological disorder. These well-founded cautions
suggest that cognitive assessment should not be limited exclusively to
the positive and negative categories. Clearly, other theoretically or empirically derived dimensions of thought also merit attention.
Yet in principle the positive - negative dichotomy in no way precludes
other categories of thought. As discussed earlier, the positive-negative
construct actually subsumes a wide array of nonidentical, but related
meanings. Rather than being exclusive, the positive-negative dimension represents a higher level of abstraction that focuses on the structural similarity of thoughts across multiple subcategories (i.e., on their
functional or evaluative significance regardless of the type of content).
For example, Schwartz and Gottman (1976) noted that the positive and
negative self-statements that best distinguished high and low assertives
centered on concern about negative self-image, fear of being disliked,
and excessive other-directedness (cf. Bruch et al., 1984). In their study of
social anxiety, Glass et al. (1982) identified through factor analysis the
subcategories of self-depreciation, positive anticipation, fear of negative
evaluation, and coping. Thus, conceptualizing positive and negative
cognitions at this level of abstraction is broadly inclusive rather than
restrictive, and complementary analyses of other dimensions of thought
can and should be performed.
The present conceptualization of polarity in the internal dialogue has
another implication for cognitive assessment. The positive-negative
dichotomy implicitly underlies such measures as the Dysfunctional Attitudes Scale (Beck, 1976; Weissman, 1979) and the Automatic Thoughts
Questionnaire (Hollon & Kendall, 1980). Research with these instruments has yielded considerable knowledge about the role of cognition in
psychopathology. However, because these are unidimensional
measures — assessing negative thoughts only—they do not tap the full
potential of the construct of polarity as a balance of opposites. To this
end, bidimensional assessment is the required strategy. That such an
approach is technically feasible is witnessed by the development of
situationally specific self-statement inventories that are easy to administer and score (e.g., Glass et al, 1982; Schwartz & Gottman, 1976), and by
increasingly sophisticated ways of assessing and categorizing open-
11
States of Mind Model
ended talking-aloud data (e.g., Davison et αϊ., 1983; Mavissakalian et αϊ.,
1983).
As the earlier excursion into philosophical and scientific conceptions
implies, understanding polarity in the internal dialogue requires that
both positive and negative dimensions be assessed. By using extant
bidimensional assessment technologies, researchers can explore the
structural aspects of clinically relevant inner speech: What are the effects of different "mixes" of positive and negative cognitions on psychological functioning? What balance between these cognitions is optimal
for coping with stress? Are there specific balances of positive and negative thoughts that distinguish functional from dysfunctional individuals?
III. THE GOLDEN SECTION HYPOTHESIS
Drawing inspiration from ancient philosophers and theologians who
were interested in the transcendental question "What proportion
should Yang and Yin bear to one another so as to yield the greatest
harmony?" (Benjafield & Adams-Webber, 1976), contemporary scientists and practitioners may profitably address the more empirical question "What proportion should positive and negative cognitions bear to
one another so as to yield harmonious, effective psychological functioning?" Interestingly, there are theoretical and empirical grounds for believing that an answer to this question can be derived from the ancient
Greek concept of the golden section.
A. The Golden Section
The golden section has captured the fascination of mathematicians,
artists, and scientists throughout history (Berlyne, 1971). In ancient
Greece, the Pythagoreans ascribed moral and mystical significance to
the golden section, and architects of the Parthenon used it to structure
the facade of this and other Greek temples. During the Middle Ages, it
was known as the "divine proportion," and Kepler called it, along with
the Pythagorean theorem, one of the two "great treasures of geometry."
Geometrically, the golden section of a line segment is illustrated in
Fig. 1. Given a whole line (AB) divided into two segments, a larger one
(AC) and a smaller one (CB), the golden section may be defined as "that
point on a line [AB] which divides it into two segments such that the
smaller [CB] is to the larger [AC] as the larger [AC] is to whole line [AB] "
(Benjafield & Adams-Webber, 1976, p. 11). The equivalence of these line
segment ratios (CB/AC = A C / A B ) implies that the major line segment
Robert M. Schwartz and Gregory L. Garamoni
12
Golden Section
A
Β
C
φ =.618
1 - φ =.382
Golden Section Proportion:
Smaller Segment (CB)
Larger Segment (AC)
Larger Segment (AC)
Whole Line (AB)
Fig. 1. The golden section of a line segment. AC must be .618 of the line AB for the
above ratios to be equal. The golden section proportion is designated φ.
(AC) must be .618, and the minor line segment (CB) must be .382 of the
whole line (AB). This can be demonstrated mathematically. Let AB = 1
(unit length of the whole line), AC = φ (major segment), and CB = 1 — φ
(minor segment); by substitution, the expression C B / A C = A C / A B is
2
equivalent to (1 — φ)/φ = φ/l; solving for 0, we get φ + φ — 1 = 0 and
1 2
then φ = ( 5 / - l ) / 2 = .618.
Mathematicians have demonstrated that the golden number (.618) is
associated with any Fibonacci sequence ( . . . 1 , 1 , 2 , 3 , 5 , 8 , 1 3 , . . . ),
which is defined as any sequence in which each number equals the sum
of the previous two numbers (e.g., 1 = 1 + 0 , 2 = 1 + 1,3 = 1 + 2). By
dividing each number by its successor, the resulting sequence of numbers increasingly approximates the golden mean of .618 (e.g., 1/2 =
.500, 2 / 3 = .666, 3 / 5 = .600, 5 / 8 = .625, 8 / 1 3 = .615). Scientists have
frequently observed this proportion in nature (Thompson, 1942; Mitcheson, 1977; Bateson, 1979). For example, growth patterns in certain
plants (e.g., flowers of dicotyledonous angiosperms) and animals (e.g.,
successive diameters of the chambered nautilus) appear to be regulated
by the golden section proportion. Readers interested in pursuing such
properties are referred to Huntley (1970) and Berlyne (1971).
The intriguing characteristics of the golden section have captured the
attention of experimental and social psychologists as well. Investigating
what had been dubbed "the most pleasing proportion," Fechner (1876)
made thousands of width/length ratio measurements of commonly
seen rectangles (e.g., windows, book covers, playing cards) and found
the average of these ratios to approximate the golden section. He also
discovered that most people expressly prefer a rectangle with proportions between a square and a double square, i.e., ones whose width/
length ratio ranges from .57 to .67, constituting what is called the
"golden rectangle." More recent controlled studies confirm that the
States of Mind Model
13
golden rectangle is judged more pleasing than other rectangular forms
(Benjafield, 1976; Piehl, 1978).
More recently, social psychologists have extended the golden section
concept beyond purely aesthetic judgments. In a representative study,
Benjafield and Adams-Webber (1976) hypothesized that when subjects
make dichotomous judgments about acquaintances, the proportion of
their positive to total positive (PJ plus negative (Nj judgments would
approximate the golden section, or P/fP + NJ = .618. Employing Kelly's
(1955) Role Construct Repertory Test, these investigators found that the
obtained mean P/fP + Nj proportions in five samples closely approximated the predicted value of .618. Interpreting these findings, Benjafield and Adams-Webber advanced the more general hypothesis that
"whenever subjects differentiate things into two, they will tend to do so
in a way that approximates the golden section" (p. 12). A series of studies
reviewed by Adams-Webber (1982) indicates that the hypothesis generalizes across an array of bipolar constructs, various methods of measurement, and different age and cultural groups. How is this unusual degree
of precision in cognitive self-regulation to be explained?
B. Theoretical Explanations
Drawing upon information theory, Berlyne (1971) explained the aesthetic preference for the golden section by arguing that "it allows the
minor element to occupy a proportion of the whole that makes it maximally striking" (p. 232). This explanation emerged from experimental
studies conducted by Frank (1959,1964), who demonstrated that when
subjects arrange colors under instruction to make one color as "striking" as possible, the "color of interest" appears 37 to 3 8 % of the time.
Thus, the proportion of figure to background makes the minor figure
maximally striking by conforming to the golden section (1 — .62 = .38).
A more theoretically grounded explanation for these findings is based
on a measure derived from information theory, which Frank (1959,
1964) called strikingness or penetrance (Aufälligkeit). In information
theoretical terms, strikingness represents "the contribution made by a
particular class of elements to uncertainty or average information content" (Berlyne, 1971, p. 231). Frank reasoned that the psychological
impact of a particular category of information elements depends on both
its information content and its relative frequency of occurrence. Therefore, an index of strikingness can be obtained by combining these two
concepts into the formula, — Pj log Pif where i represents a particular
class of information elements or signals, P, its relative frequency or
probability of occurrence, and — log P, its information content. By
summing the quantities — Pi log P, over all classes of information ele-
14
Robert M. Schwartz and Gregory L. Garamoni
ments, one obtains a measure of average uncertainty or average information, a concept central to information theory (cf. Garner, 1962). W h e n
P, = .368, the index of strikingness—quantity — P, log P,— reaches a
maximum. This formulation indicates that the contribution made by a
particular category of events to average information reaches a maximum when the relative frequency of that category (.37) approximates
the ratio of the minor to the major element in the golden section (.382)
(Benjafield & Adams-Webber, 1976).
Elaborating on the information-processing properties of the golden
section, Adams-Webber (1982) conceptualized the effects of alternative
P/(P + Nj values on discriminatory power. W h e n all figures (e.g., per
sons) are assigned to a single pole (100% positive or 100% negative), the
construct so used has no discriminatory power. When figures are symmetrically relegated to opposite poles (50% positive and 5 0 % negative),
the construct assumes maximum discriminatory power. If figures are
asymmetrically balanced, such that 6 2 % are assigned to positive poles
and 3 8 % to negative poles, the construct employed in this manner is
"theoretically optimal from the standpoint of allowing our negative
impressions to stand out maximally, and to make the greatest contribution to long-term average information" (p. 100).
Benjafield and Adams-Webber (1976) extended this line of reasoning
to explain the results of the golden section studies: "subjects tend to
organize their interpersonal judgements along bipolar dimensions so as
to make negative events maximally striking. The person tends to construe others in such a way that negative events, taken as a whole, 'stand
out' as 'figure' against a positive 'background'" (p. 14). These authors
argue that the negative poles of dichotomous constructs "tag" atypical
events that deviate from everyday norms and expectations, whereas the
positive poles refer to normal, typical events. Deviant events tend to be
those that are problematic and potentially threatening to the individual,
and hence "bear watching." From an adaptive-evolutionary perspective, an optimal information-processing strategy would indeed be one
that arranges judgments in the golden section ratio, thereby enabling an
individual to pay special attention to threatening events. Considering
the possible affective consequences of the golden section, we would add
that such an information-processing strategy also allows the person to
bask in the warm glow of moderate positivity, while being optimally set
to notice and deal with threatening events.
As suggested earlier, these figure-ground formulations implicitly
draw on two apparently contradictory information-processing biases: a
negativity bias in which negative information has relatively greater
impact than positive information (cf. Kanouse & Hanson, 1972), and a
positivity bias in which cognitive processes selectively favor pleasant
15
States of Mind Model
over unpleasant information (cf. Matlin & Stang, 1978). It can now be
seen more clearly how these two information biases complement each
other: The greater psychological impact of less frequent negative information derives in part from a background of more frequent positive
information. Although negative cognitions are in the minority, "pound
for pound they pack a greater punch" than their more frequent positive
counterparts. Thus, the golden section not only hypothesizes an optimal, asymmetrical balance of positive and negative elements, but may
also provide an explanation for the relative strikingness of negative
cognitions observed across a wide range of psychological phenomena.
IV. STATES OF MIND MODEL
Beyond the fundamental polarity of thought and the information theoretical properties of the golden section, the structural model of
positive and negative states of mind draws upon constructs derived from
an intrapersonal communication framework (cf. Meichenbaum, 1977)
and cybernetic theory (cf. Carver & Scheier, 1981). After introducing
these constructs, we then present the model itself.
A. Self-Statements and the Internal Dialogue
The states of mind model embraces the cognitive-behavioral formulation of thought as an interna] dialogue, which emerged from Ellis'
(1962), Beck's (1976), and Meichenbaum's (1977) pioneering work, according to which thought is conceptualized as inner speech or intrapersonal communication. This view can first be traced to Plato who, in
Theaetetus (189e), defined thinking as "a discourse that the mind carries
on with itself. . . . When the mind is thinking, it is simply talking to
itself, asking questions and answering them, and saying yes or no"
(Hamilton & Cairns, 1961, p. 895). Although the strict Watsonian (1925)
position that thought is nothing hut talking to ourselves is indefensible
(cf. Bernard, 1981; Vendler, 1977), this conception nevertheless has heuristic value that permits a meaningful application of concepts of interpersonal communication to the domain of intrapsychic functioning.
Furthermore, the notion of an internal dialogue has a psychological
reality that justifies its use. Following Guidano and Liotti (1983), dialogue rather than monologue is adopted here as the generic term because it captures the phenomenological sense of an inner dialogue between internalized figures or different self-aspects, as well as the
dialectical interaction between positive and negative thoughts that is
central to the present model. Only the less frequent states of mind in
which positive or negative elements predominate to the extent that the
Robert M. Schwartz and Gregory L. Garamoni
16
dialectical process is relatively abandoned are considered monological
forms of inner speech.
The terms positive and negative self-statements, which are a primary
(although not exclusive) focus of the present model, require clarification. Self-statements are statements to oneself (self-talk), but not necessarily about oneself (self-consciousness) (cf. Kenny, 1976). Thus, selfstatements may be either self-referential ("I was thinking how
embarrassed I get when I ask someone out") or not self-referential ("I
was thinking about when the Dodgers played in Brooklyn"). As discussed earlier, the terms positive and negative refer to the functional or
evaluative-affective significance of self-statements.
B. Overview of States of Mind Model
The present model proposes five distinct states of mind (SOMs) conceptualized within an intrapersonal communication framework (see
Fig. 2). The three dialogic SOMs (positive dialogue, internal dialogue of
m
[Tool
.68
M
LES
.56
.55
.45
El
El
•44
.32
M
m
00
POSITIVE
MONOLOGUE
POSITIVE
DIALOGUE
INTERNAL
DIALOGUE
OF C O N F L I C T
NEGATIVE
DIALOGUE
NEGATIVE
MONOLOGUE
Fig. 2. Structural model of positive and negative states of mind. The dialogic and monologic states of mind are conceptualized within an intrapersonal communication framework and defined by the relative balance between positive (P) and negative (N) cognitions.
States of Mind Model
17
conflict, and negative dialogue] and the two monologic SOMs (positive
and negative monologue] are based on the relative balance between
positive and negative cognitions. Consistent with the golden section
literature, these SOMs are defined by the proportion of positive cognitions to positive plus negative cognitions or P/(P + NJ. The exact figures
or SOM proportions defining each SOM can be seen in Fig. 2 within the
left portion of each set of bars. The negative element of each SOM is
defined by the proportion of negative to positive plus negative cognitions, or N/(P + Nj, as can be seen in the right portion of each set of bars.
A sixth distinct SOM (not shown in Fig. 2), inner speechlessness, is
defined by the relative absence of self-verbalization rather than the
proportion of positive and negative cognitions. Thus, the two basic parameters of the model are balance and overall frequency: The primary
focus is on the balance or harmony of positive and negative cognitions,
although overall frequency has potential significance as well.
In addition to these quantitative parameters, each SOM is qualitatively described in terms of symmetry, balance, stability, discriminatory power, and associated clinical features. These properties, which are
summarized in Table I, will be elaborated shortly in a more detailed
description of each SOM.
1. Cognitive-Affective
Set Point
1
Before turning to the individual SOMs, the concept of cognitive affective set point must be introduced. The dialogic SOMs (positive dialogue, internal dialogue of conflict, and negative dialogue) are defined in
terms of specific cognitive - affective set points and ranges that surround
the set point. The monologic SOMs (positive and negative monologue)
do not have specific set points and are thus defined only in terms of
ranges (see Fig. 2).
The cognitive-affective set points are derived from information-processing principles associated with the golden section (cf. Adams-Web-
*Γη this context, the terms "cognitive-affective" and "cognitive" have been used interchangeably even though the conceptual distinction between cognition and affect is important. For example, Turk and Speers (1983) observed that schemata, or organized
knowledge structures, have both ideational and affective components. In practice, however, these subcomponents of experience are frequently overlapping, interdependent,
and confounded (cf. Harrell, Chambless, & Calhoun, 1981; Ellis, 1984; Schwartz, 1982,
1984). Consequently, it was not possible to determine from the studies that were reviewed
(Schwartz & Garamoni, 1986a) whether the hypothesized SOM proportions were obtained
for the cognitive component, the affective component, or both, or to identify possible
interactions. Whether the set points obtain for both cognition and affect when these are
not confounded by the assessment procedures must therefore remain a problem for future
research.
18
Properties
Monologicdialogic
Symmetricalasymmetrical
Balancedimbalanced
Stableunstable
Discriminatory
power
Properties/
features
Balanced
Balanced
Stable
Optimal for
negative
Unstable
Minimal
Maximal
Stable
Symmetrical
Asymmetrical
Asymmetrical
(lopsided)
unbalanced
Dialogic
Internal
dialogue
of conflict
Dialogic
Positive
dialogue
Monologic
Positive
monologue
States of mind
Optimal for
positive
Stable
Balanced
Asymmetrical
Dialogic
Negative
dialogue
TABLE I
Properties and Associated Features of Theoretical States of Mind
Minimal
Unstable
Asymmetrical
(lopsided)
Imbalanced
Monologic
Negative
monologue
19
Nonclinical
examples
Transient elation in
response to
positive events
(e.g., success, peak
experiences)
Associated features
Clinical
Unrealistic optifeatures
mism, inattentiveness to threat,
grandiosity,
vulnerability to
shock, impulsiveness
Related
Mania, hypomania,
disorders
narcissism
Ongoing adaptive,
realistic, coping
behavior
Moderate anxiety/
depression
Mild anxiety/depression, obsessive
traits
Transient doubt/
conflict in
response to challenges (e.g.,
decisional or ereative dilemmas)
Transient dysphoria
in response to
major life events
(e.g., job loss,
divorce)
Moderate pessimism,
guilt, impaired
self-esteem,
avoidance
behavior
Ambivalence,
indecisiveness,
uncertainty,
self-doubt, worry,
procrastination
Transient grief/
panic in response
to catastrophes
(e.g., terminal illness, trauma,
victimization)
Severe anxiety/depression
Undiluted pessimism, pervasive
guilt, feeling of
worthlessness,
panic states,
withdrawal
20
Robert M. Schwartz and Gregory L. Garamoni
ber, 1982; Berlyne, 1971) and from logical and empirical considerations
associated with the "internal dialogue of conflict" (cf. Schwartz & Gottman, 1976; Schwartz & Garamoni, 1984). The set point concept itself is
derived from cybernetic and information-processing theory as outlined
by Carver and Scheier (1981). In cybernetic, self-regulating systems
there exists an "intrinsic motivation" to maintain a fixed reference
value or set point. Discrepancies from this set point are detected by a
"sensor" or "comparator" that matches the existing state to the reference value. When such discrepancies occur, the cybernetic processes
governing the system result in the initiation of adaptation, self-regulation, or coping to restore the lost balance.
This process is typically illustrated by the concept of homeostasis
introduced by Cannon (1932). As presented by Hassenstein (1971) and
Carver and Scheier (1981), the body temperature of warm-blooded animals is controlled in such a manner. Deviations in body temperature
from the normal set point of 37°C will be detected by the sensor mechanism, and result in changes in the functioning of body organs intended
to restore equilibrium or homeostasis (Carver & Scheier, 1981).
The dialogic SOMs are hypothesized to function as cybernetic systems that are analogous to other self-regulatory processes such as body
temperature and blood pressure. The set points of these SOMs represent
pre/erred forms or structures because of their associated informationprocessing properties. Individuals are thus hypothesized to monitor
their thoughts and feelings with considerable accuracy in order to
maintain the balance of positive and negative elements determined by
the cognitive-affective set point. This self-monitoring is presumed to
occur at the level of both automatic and controlled processing
(Schneider & Shiffrin, 1977). Similar to other cybernetic processes,
when the actual SOM varies significantly from the set point, self-regulatory actions are initiated to return to equilibrium. In functional individuals, this set point is hypothesized to be the golden section proportion of
.618, and variations in either direction from this set point represent
increasing degrees of psychopathology.
2. States of Mind Ranges
In addition to the set points that define the dialogic SOMs, each SOM
is also defined by an SOM range. As Carver and Scheier (1981) noted,
even the set point for temperature regulation is not fixed precisely. In a
fever, for example, body temperature is elevated to a level higher than
normal, and the body's self-regulating system does not attempt to reduce it as would normally occur. Instead, the system acts to maintain
this new temporary set point until conditions return to normal. Simi-
States of Mind Model
21
larly, an individual's SOM is not constantly fixed at the specified set
point, but fluctuates to some degree as a function of both internal and
environmental circumstances. For this reason, and because of inherent
errors of measurement, it is meaningful to construct ranges for each
SOM category.
For reasons to be explained shortly, the set points of the positive
dialogue, internal dialogue of conflict, and negative dialogue are fixed at
.62, .50, and .38, respectively (see Fig. 2). If the distance between the
positive dialogue set point of .62 (rounding to two decimal places) and
the internal dialogue of conflict set point of. 50 is divided equally, we are
left with .62 - .50 = .12; . 1 2 / 2 = .06. Adding this number (.06) to the
positive dialogue set point of .62 yields the upper limit of the positive
dialogue range (.62 + .06 = .68). Subtracting .06 from .62 yields the
lower limit of this range (.62 — .06 = .56). Thus, the positive dialogue
range is defined as the golden number .62 ± .06, or .56 to .68 (see Fig. 2).
Similarly the negative dialogue range can be constructed by adding and
subtracting .06 to the set point of this SOM, or .38 ± .06. As can easily be
seen, this results in a negative dialogue range of .32 to .44. With these
ranges thus defined, the internal dialogue of conflict range is automatically established as .45 to .55. Similarly, positive and negative monologue ranges are respectively defined as P/(P + N] proportions falling
above the positive dialogue range ( ^ .69) and below the negative dialogue range ( ^ .31) (see Fig. 2).
C. States of Mind Defined
1. Positive Dialogue (Golden Dialogue]
a. Definition.
The positive dialogue (PD) is an internal dialogue characterized by asymmetrically balanced structures of positive (PSS) and
negative self-statements (NSS), such that PSS and NSS constitute .618
and .382 of the structure, respectively. The PD range is defined as
.62 ± .06 = .56 to .68 (see Fig. 2).
b. Theoretical and Clinical Formulation.
Based on the golden section research, the PD is hypothesized to be the optimal SOM for coping
with stress and for general psychological adaptation. Such an SOM
allows the individual to maintain a state of general positivity in cognition and mood, while remaining maximally attentive to negative,
threatening events. The positive dialogue constitutes an optimal balance (cf. Berlyne, 1960; Hebb, 1955), since more negative as well as more
positive SOMs are considered maladaptive.
Kelly (1955) originally regarded "lopsided" constructs (i.e., ones that
varied from a 5 0 / 5 0 split) as either a methodological nuisance or an
indication of psychological maladjustment. In contrast, the golden sec-
22
Robert M. Schwartz and Gregory L. Garamoni
tion implies that a slight degree of "lopsidedness"— what we are calling
asymmetry—constitutes an optimal balance. Addressing this issue experimentally, Ridgon and Epting (1982) found that subjects perceived
greater usefulness in constructs that they used in the 6 2 % / 3 8 % proportion. As judged by the individual, constructs that are asymmetrically
balanced in this specific proportion are the most useful for noticing
differences between people and presumably for coping with interpersonal situations.
Table I indicates that this SOM is dialogic, asymmetrical, balanced,
stable, and optimally discriminatory for negative events. The PD is dialogic because opposing positive and negative constituents are both substantially represented; it is asymmetrically balanced in that PSS are
slightly overrepresented relative to NSS rather than being structured
according to a 5 0 / 5 0 bilateral symmetry. T h e term balance suggests
proportionality or good form: Polar opposities are not arbitrarily
blended, but are precisely represented to create an equilibrium that has
theoretically defined adaptive value.
Because this structure is characterized by good form (Gestalt), it is
considered relatively stable. In discussing pattern goodness, Garner
(1974) noted that "a poor pattern is one that is perceived as unstable,
easily changed, as having, in fact many alternatives . . . good patterns
are those perceived as stable, not easily changed, and as having few
alternatives" (p. 16). Thus, normal individuals are expected to strive to
maintain this preferred form, such that variations from the PD set point
initiate self-regulatory activities to restore equilibrium, a process that
results in a relatively stable state. Lastly, the PD has optimal discriminatory power because it preserves the greatest background of positivity,
while allowing negative events to stand out maximally and make the
largest contribution to long-term average information.
The clinical significance of the PD can be illustrated by the appropriately assertive individual who engages in sufficient facilitory self-talk to
initiate assertive behavior, while balancing this with enough inhibitory
thought to remain interpersonally sensitive. Overly negative thinkers
will inhibit necessary assertiveness (Schwartz & Gottman, 1976), and, as
shown by Safran (1982), excessively high positive thinkers are judged to
be irritable and brusque. Similarly, the low test anxious person is not
entirely free of negative self-talk. Thoughts such as "it might be difficult" and "I may fail" are inevitable parts of the reality of evaluative
situations and, if present in the correct proportions, can facilitate performance (Arnkoff & Glass, 1982; Kendall & Hollon, 1981). Galassi,
Frierson, and Sharer (1981) found that low and high test anxious students did not differ in the types of positive and negative thoughts present
during examinations, but only in their relative frequencies. The rank
23
States of Mind Model
ordering from most to least frequent of 10 positive and 10 negative
thoughts was about the same for both groups. Thus, the groups were
distinguished not by "pathognomonic" thoughts unique to the dysfunctional group, but by the relative balance of positive and negative cognitions. The PD allows the competent test taker to be as confident as
possible, while still engaging in enough realistic negative thought to
remain maximally sensitive to potential dangers of the situation.
Thus, the PD characterizes the well-adjusted individual who balances the positive and negative elements of cognitive-affective structures in j ust the right proportions — who avoids the extremes of too little
or too much. The PD (or "golden dialogue") is similar to what the ancient
Greeks referred to as sophrosynë (literally, whole mindedness) or moderation. This is the adaptive, flexible, resilient coper whose structures
are optimally and asymmetrically set to maintain a general sense of
overall well-being, while at the same time being poised to deal with
inevitable negative events. This is the cautious and realistic optimist.
2. Negative Dialogue (Inverse Golden Section)
a. Definition.
The negative dialogue (ND) is an internal dialogue
characterized by asymmetrically balanced structures of positive and
negative self-statements, such that PSS and NSS constitute .382 and .618
of the structure, respectively. The ND range is defined as .38 ± .06 = .32
to .44 (see Fig. 2).
b. Theoretical and Clinical Formulation.
The ND is hypothesized to
be a moderately pathological SOM in which negative thoughts and feelings predominate. The form of this SOM is the complete rotation or
inverse of the PD, such that the defining proportion of .382 is derived
from 1 — .618 = .382 (see Fig. 2). Thus, it is derived directly from the
golden section proportion, but represents a reversal of this preferred
balance.
According to the Gestalt concept of pattern goodness and supporting
experimental evidence, when a given pattern is preferred ("goodness of
form"), there is usually a preference for the systematic reflections a n d /
or rotations of the pattern. For example, if a given configuration of dots is
rated as a good form, any clockwise 90° rotation of the original form that
is structurally equivalent will also receive similar ratings (Garner, 1974;
see also Weyl, 1952). Since the ND represents a 180° rotation of the
optimal PD, the ND is a structurally preferred form, even though its
content is predominantly negative.
An empirical finding by Averill (1980) also suggests that the 180°
rotation of the golden section proportion is a preferred form in human
information processing. Although there is an overall preponderance of
positive words in the English language (cf. Matlin & Stang, 1978), Averill
24
Robert M. Schwartz and Gregory L. Garamoni
found that for the 558 distinct emotional concepts identified, negative
terms exceeded positive ones. Specifically, positive affect terms comprised precisely 38% and negative terms, 62%, which is an exact reversal of the golden section proportion. Although tentative, these theoretical and empirical factors suggest that human information processing is
designed such that the SOM defined by the inverse golden section, or
.382, constitutes a preferred set point.
Table I indicates that the ND has properties similar to the PD—it is
dialogic, asymmetrical, balanced, and stable. It is also optimally discriminatory, but for positive rather than negative events. Because a
negative rather than positive asymmetric balance is maintained, the
person engaged in an ND represents a "failed dialectician": The fundamental positive/negative dialectic and the sense of good form (proportionality) are both maintained; however, the dialectical process is unsuccessful because the favorable positive/negative balance and the
adaptive information-processing properties associated with the golden
section are lost.
Since this SOM inverts the golden section, it follows logically and
mathematically that the discriminatory power of the ND is "optimal"
for maintaining a background of negativity, while making positive
events maximally striking. Such an SOM is emotionally costly, but can
have adaptive value for individuals who expect higher frequencies
of negative events or who are predisposed to overreact to negative experiences. The price paid for this strategy is a background of continual,
moderate negativity; the apparent gain is that when negative events do
occur, they are less shocking and can be more easily assimilated into
existing structures.
That the ND maximizes the strikingness of positive rather than negative events initially seems counterintuitive. But consider, for example,
the individual with low self-esteem whose hypersensitivity about failure leads to incessant worry about poor performance. Although chronically dysphoric and tense, this person's cognitive-affective structures
are, at the least, prepared for anticipated performance failures. Indeed,
for such persons, it is positive events that stand out figurally against a
background of negativity, "bear watching," and are often difficult to
believe and assimilate. Negative events, though always painful, are
more congruent with the dominant element of this SOM.
Clinically, this SOM characterizes the moderately disturbed individual whose set point is established at an unfavorable balance. For example, moderately nonassertive persons engaged in an ND would frequently inhibit their assertive behavior because of an excess of negative
thought. Similarly, moderately depressed persons are hypothesized to
have asymmetrically balanced negative self-schema, internal dia-
States of Mind Model
25
logues, and affective states. Once this pathological SOM is established
— through environmental a n d / o r biological factors—such persons
will strive to maintain what becomes a "preferred level of dysphoria or
fear/' Since the system is regulated by this negative reference value,
even positive changes towards the golden section may result in stress,
anxiety, and resistance.
3. internal Dialogue of Conflict (Ambivalence]
a. Definition. The internal dialogue of conflict (IDC) is an internal
dialogue characterized by symmetrically balanced structures of positive and negative self-statements, such that PSS and NSS each constitute
.500 of the structure. The IDC range is defined as .50 ± .05 = .45 to .55
(see Fig. 2).
b. Theoretical and Clinical Formulation. Whereas the set points of
the PD and ND are derived from the information-theoretical properties
of the golden section, the set point of the IDC is rationally defined by that
point which creates a bilateral symmetry or equivalence between the
positive and negative elements. The IDC is also empirically grounded in
work by Schwartz and Gottman (1976), who found that nonassertives
were characterized by an equal amount of PSS and NSS (cf. Bruch, 1981;
Heimberg et αϊ., 1983). This SOM is similar to the concept of
ambivalance—the
coexistence of antithetical ideas, attitudes, or emotions toward a given object or situation (Bleuler, 1914). Since positive
thoughts or feelings are balanced by an equal number of negative ones,
such SOMs result in conflict, indecisiveness, and stasis. The individual
is left, so to speak, to the fate of Buridan's ass — "starving in indecision
between two equal bundles of hay" (Rescher, 1972, p. 428).
Table I indicates that the IDC is dialogic, symmetrical, balanced,
stable, and maximally (not optimally) discriminatory. Thus, two structural features distinguish the IDC from the PD and ND: The IDC is
composed of symmetrically rather than asymmetrically balanced structures; and the discriminatory power is maximal because the 5 0 / 5 0 split
differentiates most completely the constituent positive and negative
elements. Maximal discrimination and symmetrical balance in a mental
structure are not optimal because they lead to an excessively differentiated and static (ambivalent) construct system.
However, transitory states of IDC are both healthy and necessary to
growth and development. Conceptual conflict is a primary motivation
in directed thinking, epistemic behavior, and curiosity (Berlyne, 1960,
1965). A degree of doubt, perplexity, and even contradiction is needed in
the process of problem solving and the equilibration of higher level
cognitive structures (cf. Piaget, 1977). The need for temporary swings
into an IDC before reaching a resolution—with periodic alternations
26
Robert M. Schwartz and Gregory L. Garamoni
between positive and negative thought — is consistent with Janis and
Mann's (1977) model of coping with decisional stress. Only when the
conflictual state becomes established as a permanent set point does the
IDC become pathological.
Clinically, this SOM is associated with mild anxiety, depression, and
obsessional traits. An IDC will delay and sometimes inhibit appropriate
behavior in the mildly fearful and nonassertive individual who cannot
refuse an unreasonable request because positive thoughts impelling
toward refusal are countered by inhibitory thoughts concerning potential negative consequences. The cognitive-affective structures of
mildly depressed persons are symmetrically balanced such that the
self-referential internal dialogue and the affective state are dominated
neither by positive nor negative elements. Alternatively, the creative
person whose ongoing SOM is a PD may experience an adaptive (if
transient) IDC while contemplating the horns of an aesthetic dilemma.
4. Positive Monologue (PoiJyannaism)
a. Definition. The positive monologue (PM) is an internal monologue
characterized by asymmetrically imbalanced structures of predominantly positive self-statements, such that PSS constitute .69 or more,
and NSS .31 or less, of the structure (see Fig. 2).
b. Theoretical and Clinical Formulation. The PM is a maladaptive
SOM in which positive thoughts and feelings exceed the optimal balance specified by the golden section proportion. The PM is most clearly
exemplified by certain forms of hypomania and mania, with the associated features of grandiosity, denial, impulsiveness, and unrealistic
optimism. In contrast to the previously described dialogic SOMs, the PM
and the negative monologue (NM) lack specific set points and are defined only by their ranges.
Table I indicates that both the PM and NM are monologic, asymmetrical (lopsided), imbalanced, unstable, and minimally discriminatory.
These SOMs are monologic in form because (relatively speaking) they
abandon the dialectical tension of opposites that characterizes the three
dialogic SOMs. This becomes increasingly evident as the P/(P + NJ proportions approach 0 or 1. The PM and NM are asymmetrically imbalanced rather than balanced because the extreme overrepresentation of
either positive or negative elements does not constitute ''good form" — a
degree of asymmetry that is "lopsided" in the sense originally intended
by Kelly (1955). Lacking set points, the monologic SOMs are inherently
unstable, striving to return to the more balanced and less extreme dialogic SOMs. In bipolar spectrum disorders (Akiskal, 1982), a failure to
reestablish a dialogic set point can lead to periodic oscillations between
the PM and NM.
States of Mind Model
27
From an information-processing perspective, the PM (relative to the
PD) represents a gain in positivity at the expense of a loss in discriminatory power and strikingness of negative events. Extreme PMs represent
a complete lack of discriminatory power such that the world is perceived in a global and undifferentiated way — as undiluted positivity
(cf. Werner, 1957). Although more immediately reinforcing, this SOM is
not optimal in the long run: Important threatening events may be unattended to entirely (e.g., cardiac symptoms, threats to marital harmony,
accident potential); furthermore, when awareness of inevitable negative events can no longer be denied, shock or disappointment may result
because adequate schemata are not available to assimilate these occurrences (cf. Goldfried & Robins, 1983; Turk & Speers, 1983).
Although not addressed directly to SOMs, experimental evidence
suggests that excessive positivity can have undesirable interpersonal
and performance consequences. Safran (1982) found that high positive
thinkers in assertive situations were viewed as irritable and brusque.
Wade (1974) demonstrated that subjects who monitored correct (positive) responses during a perceptual matching task had higher initial
scores, but over time their performance deteriorated relative to those
who monitored incorrect responses. Similarly, Tomarken and Kirschenbaum (1982) found that during a graduate admissions preparatory
class, positive self-monitoring (relative to negative) led to decreased
accuracy, less time in self-observation, lower rates of attendance, and
lower levels of persistence. Taken together, these results support Tomarken and Kirschenbaum's challenge to the wisdom of the once popular song that advised, "Accentuate the positive."
This notion is also supported by cultural admonitions against excess
positivity, as in the Greek myth of Icarus who courted disaster by flying
too close to the sun and the theologically based warning that "pride
goeth before a fall." Clinically, the PM characterizes the inappropriately
assertive individual who violates the often made distinction between
assertion and aggression. An excessive degree of positivity about one's
own rights may result in overlooking the feelings of others. In performance situations, the PM is associated with the proverbially "cocky"
person who fails to notice potential problems and is crushed by unexpected defeat. The forced cheerfulness of the person engaging in denial
or the uncontrolled euphoria of the manic are classic illustrations of this
SOM.
Depending on situational factors, temporary and moderate swings
into the PM can be adaptive, as in the transitory elation experienced
during periods of creative discovery or "peak experiences" (Maslow,
1968). But generally the quip that "anyone who thinks too positively is
just not paying attention" appears to have initial experimental support.
28
Robert M. Schwartz and Gregory L. Garamoni
A sustained PM is maladaptive because it does not heed the warning to
avoid too much or too little, thus violating the "asymmetrical golden
mean."
5. Negative Monologue (Undiluted Pessimism]
a. Definition. The NM is an internal monologue characterized by
asymmetrically imbalanced structures of predominantly negative selfstatements, such that PSS constitute .31 or less, and NSS .69 or more, of
the structure (see Fig. 2).
b. Theoretical and Clinical Formulation. The NM is an SOM with
relatively undiluted negativity that is associated with extremely severe
psychopathological states. Since the form of the NM represents a complete reversal of the PM, both SOMs share the same structural properties: They are monologic, asymmetrical (lopsided), imbalanced, unstable, and minimally discriminatory (for reasons outlined in the
discussion of the PM). The distinguishing feature of the NM, of course, is
the predominance of negative cognition/affect (see Table I).
Relative to the IDC and ND, the NM represents more than simply a
quantitative (negative) shift on the continuum of SOM proportions. As a
qualitatively unique SOM, the NM exhibits distinct structural and information-processing properties — a critical one being its hypothesized
instability. Although clinical experience suggests that some severe unipolar depressions can be relatively prolonged, the SOM model holds
that stable and enduring negative thinking more typically approximates
the set points of the IDC or ND; when the SOM becomes more uniformly
negative, as in the NM, internal or external pressures will be exerted to
move the individual toward more positive thinking—to reestablish a
more balanced, dialogic SOM. Self-regulatory processes within severely
depressed persons, for example, may reassert themselves and partially
improve the SOM, as witnessed in spontaneous remissions in some
unipolar depressions (Beck, 1972). Should this fail, external sources are
likely to intervene with hospitalization or psychotropic medications.
Thus, NMs are less likely to endure than the more stable, dialogic SOMs
and therefore are less frequently encountered.
Clinically, the NM is exemplified by nonmedicated, profound depressive states (e.g., a psychotically depressed person plagued by delusions
of complete worthlessness and undiluted evil) or acute stages of severe
panic. In nonassertiveness, an NM represents a total denial and inhibition of the self, sometimes found in persons with extreme masochistic
tendencies. At the early stages of coping with catastrophe (e.g., traumatic loss, victimization), a brief period of NM may be adaptive; but if
sustained, even moderately, it has obvious maladaptive implications.
29
States of Mind Model
As with the PM, the NM also violates the "asymmetrical golden mean,"
but without the superficial charm of Pollyannaism.
6. Inner Speechlessness
(Mindlessness)
a. Definition. Inner speechlessness (IS) is an SOM characterized by
an overall frequency of PSS and NSS that approaches zero. The defining
characteristic is the relative absence of self-statements rather than their
balance.
b. Theoretical and Clinical Formulation.
Distinct from the monologic and dialogic SOMs, IS represents the logical completion of a linguistically based model. Instead of conscious, semantically encoded ideation, IS suggests other modes of information processing—perceptual,
kinesthetic, affective, and unconscious. Thus, right hemispheric processing may be associated with this SOM (cf. Kinsbourne, 1978; Tucker
& Williamson, 1984). Because this state is defined as the absence of inner
speech, dimensions such as monologic/dialogic or balance/imbalance
do not apply.
IS is similar to what Langer (1978) has referred to as mindlessness.
Challenging the current accounts of social behavior that emphasize the
role of thoughtfulness, Langer conducted a series of experiments to
show that many overlearned behaviors occur as a function of scripts
without the support of conscious ideation or internal dialogue. As a form
of "healthy mindlessness," IS represents states of smooth and automatic
information processing associated with well rehearsed and problem free
spheres of functioning; in its unhealthy forms, it can signify denial,
repression, or mental insufficiency.
Meichenbaum (1977) noted the importance, in certain situations, of
eliminating the internal dialogue rather than training people to talk
more effectively to themselves. He cited Gallwey (1974), for example,
who advised athletes to use imagery and engage in a "benign period of
verbal neglect." Related ideas are the Zen Buddhist concept of Wu-hsin
("no-mindedness") and Polanyi's (1966) notion of "tacit knowledge" —
that is, knowledge of practical operations without the ability to articulate their rules.
An implication of this SOM is that one must know not only what one
should say to oneself to overcome problems, but also when to speak and
when to remain silent: Just as interpersonal communication is governed
by the need for verbal restraint, so may it be with internal dialogue. In a
study of novice parachutists, for example, Girodo and Roehl (1978)
found that self-instructional training impaired aspects of their performance and suggested that the self-talk may have interfered with other
forms or levels of information processing.
30
Robert M. Schwartz and Gregory L. Garamoni
In general, the therapeutic value of modifying the internal dialogue
has been established (Dush, Hirt, & Schroeder, 1983; Miller & Berman,
1983). However, IS suggests that periods of inner quiet may also play an
important role in certain types of learning situations and at certain
phases of cognitive-affective restructuring (cf.. Kendall, 1982, 1983).
This SOM may be most relevant in heavily motoric and automated
behaviors, such as sports or musical performance; in behaviors requiring minimal ideational activity, such as sexual intercourse or falling
asleep; and in treating disorders of physiological self-regulation, such as
stress and autonomic hyperarousal.
Another application of IS can be derived from William James ( 1 8 9 9 /
1963), who recommended a descent to a more primitive and profound
"non-thinking level . . . of pure sensorial perception" as an antidote
for the "over-educated pessimist" — the nineteenth century version of
the contemporary, overideational obessional. To illustrate this point,
James cited a Mr. W.H. Hudson's description of his solitary winter experience on the Rio Negro:
All day there would be no sound, not even the rustling of a leaf . . . while listening to
the silence . . . it was a rare thing for any thought to cross my mind. In the state of
mind I was in, thought had become impossible. My state was one of suspense and
watchfulness; yet I had no expectation of meeting an adventure and felt as free from
apprehension as I feel now while sitting in a room in London. The state seemed
familiar rather than strange, and accompanied by a strong feeling of elation; and I did
not know that something had come between me and my intellect until I returned to
my former self—to thinking, and the old insipid existence [again], (p. 268)
The state of IS depicted here transcends the dross that sometimes characterizes everyday cognition and draws upon deep internal resources
and modes of information processing that can supplement the various
forms of internal monologue and dialogue presented in the SOM model.
V. EMPIRICAL EVALUATION OF THE MODEL
A recent empirical test of several major hypotheses derived from the
SOM model demonstrated that the model organizes and fits data from
extant cognitive-behavioral research on anxiety and depression
(Schwartz & Garamoni, 1984, 1986a). This review included 27 studies
that reported data suitable for evaluating these hypotheses. Of these, 22
were group contrast studies in which functional and dysfunctional
groups (e.g., assertives versus nonassertives) were compared on measures of positive and negative cognitions (see Table II). The remaining
five were psychotherapy outcome studies in which treatment groups
were compared on pretreatment a n d / o r posttreatment measures of positive and negative cognitions (see Table III).
Klass ( 1 9 8 1 ) , low ve, s high
guilt-over-assertion lemale
students
Schwartz & Gottman ( 1 9 7 6 ) ,
high versus low assertive
students
Bruch ( 1 9 8 1 ) , high versus low
assertive students
Heimberget al ( 1 9 8 3 ) , high
versus low assertives
Students
Adults
Psychiatric inpatients
Pitcher & Meikle ( 1 9 8 0 ) , high
versus low assertive adults
Study
Inventory/ASST d
Negative
Positive
Combined
Inventory/thought
inventory
Inventory/
ASST-RC
Inventory/ASST b
Inventory/ASST b
Cognitive
assessment
method/
measure
Negative
5 0 . 0
3 8 . 6
1 1 . 0
7.6
9.3
2 7 . 2
2 3 . 2
4 4 . 0
3 9 . 0
1 6 . 7
1 9 . 2
1 8 . 0
2 3 . 8
3 5 . 0
4 1 . 8
5 9 . 0
3 3 . 0
Assertiveness
5 7 . 0
PD
PD
PD
SOM
. 6 0 2 PD
. 7 1 6 PM
. 6 5 9 PD
. 5 6 4
PD
. 6 1 8 PD
. 6 2 7 PD
. 6 3 7
. 6 2 7
. 6 3 3
^
P+ Ν
Social-evaluative anxiety
Positive
Cognitions (M)
Functional group
5 4 . 4
1 3 . 8
1 8 . 5
1 6 . 2
3 6 . 1
3 8 . 0
4 8 . 0
4 8 . 0
Positive
5 0 . 5
1 4 . 9
9.5
1 2 . 2
3 3 . 8
3 3 . 2
5 1 . 0
5 1 . 0
Negative
Cognitions (M)
IDC
IDC
IDC
SOM
(continued)
. 4 8 1 IDC
. 6 6 1 PD
. 5 7 1 PD
. 5 1 9
IDC
. 5 1 6 IDC
. 5 3 3
. 4 8 5
. 4 8 5
^
Ρ+ Ν
Dysfunctional group
States of Mind (SOM) and Associated P/[P + N) Proportions: Group Contrast Studies0
TABLE II
32
Cacioppo et aJ. (1979), low
versus high socially anxious
students
Glass et al (1982)
Sample 1
Low versus high socially
anxious students
High skill/low anxious
versus low skill/high
anxious students
Combined
Sample 2
High skill/low anxious
versus low skill/high
anxious students
Females
Males
Combined
Study
Inventory/SISST'
Production/
thought listing8
Cognitive
assessment
method/
measure
Negative
33.3
28.4
30.9
31.7
34.2
33.0
55.0
58.4
56.5
56.3
53.5
54.9
Social anxiety
1.6
1.2
Positive
Cognitions (M)
.640
.610
.625
.646
.673
.623
.571
Ρ
Ρ+ Ν
Functional group
TABLE II (Continued)
PD
PD
PD
PD
PD
PD
PD
SOM
46.5
38.8
42.7
46.4
43.2
49.6
1.5
Positive
42.7
51.9
47.3
45.0
51.0
38.9
2.0
Negative
Cognitions (M)
.521
.428
.474
.508
.459
.560
.429
Ρ
+
Ρ Ν
Dysfunctional group
IDC
ND
IDC
IDC
IDC
PD
ND
SOM
33
Kuiper & Deny (1982)
Experiment # 1 , nondepressed versus mildly depressed students
Experiment #2, nondepressed versus mildly depressed students
Hollandsworth et al (1979),
low versus high test anxious
students
Galassi et al (1981), low
versus high test anxious
students
Haiford & Foddy (1982), low
versus high socially anxious
students
Merluzzi et al (1983), low
versus high socially anxious
students
Incidental
recall/recall
ratio h
Depression
2.2
.741
.24
.12
.667
MiJdJy depressed undergraduates
.26
.10
.722
Inventory/checklist
6.3
.678
Test anxiety
67.3
32.0
Production/PVTR*
.662
28.1
55.0
Inventory/SISST'
.768
1.3
4.3
Inventory/checklist
PD
PM
PM
PD
PD
PM
.16
.27
4.1
45.0
44.1
4.4
.24
.26
5.3
61.3
42.7
4.9
ND
IDC
ND
ND
IDC
IDC
(continued)
.400
.509
.436
.423
.508
.473
34
Incidental
recall/recall
ratioh
Derry & Kuiper (1981)
Nondepressed females
versus moderately
depressed female patients
Nondepressed female
psychiatric patients
Clark & Teasdale (1982),
diurnally less versus more
depressed inpatients.
Associative
recall/recall %'
Incidental
recall/recall
ratioh
Incidental
recall/recall
ratioh
Kuiper & MacDonald (1982),
nondepressed versus mildly
depressed students
Dyck et al (1983), nondepressed versus mildly
depressed students
Study
Cognitive
assessment
method/
measure
.12
.25
+
.37
.17
.24
.51
.10
.25
Ν
.676
.692
Ρ
.580
.585
.714
Moderately depressed patients
.08
Negative
.18
Positive
Cognitions (M)
Functional group
TABLE II (Continued)
PD
PD
PM
PD
PM
SOM
.38
.14
.28
.22
Positive
.52
.28
.26
.18
Negative
Cognitions (Μ)
+
Ν
.422f
.333f
.519
.550
Ρ
ρ
Dysfunctional group
ND
ND
IDC
IDC
SOM
35
Vasta & Brockner (1979), high
versus low self-esteem
students
Bradley & Mathews (1983)
Nondepressed adults versus
moderately (primary)
depressed inpatients
Anxiety neurotics with
moderate (secondary) depression
Missel & Sommer (1983),
nondepressed versus
moderately depressed inpatients
Dunbar & Lishman (1984),
nondepressed normals
versus depressed inpatients
Production/
thought
sampling
Inventory/SVQ k
Failure
Success
Combined
Recognition/SDT
d' value 1
Free recall/recall
frequency'
4.60
3.30
8.00
.80
5.30
Self-esteem
2.40
1.50
Miscellaneous
5.90
8.70
14.70
1.30
6.60
.615
.562
.725
.648
.619
.555
PD
PD
PM
PD
PD
PD
2.30
2.00
9.30
6.80
16.10
1.10
5.00
5.50
3.20
5.10
8.30
.90
5.90
3.90
IDC
NM
ND
ND
IDC
IDC
ND
(continued)
.535
.256
.429
.340f
.450f
.524f
.398f
36
Production/free
association
Ideas
Images
Combined
Past content
Future content
Negative
17.59
26.50
22.05
15.88
10.65
12.58
14.42
13.50
9.92
1.24
Mixed abnormality
Positive
Cognitions (M)
.583
.648
.620
.616
.896
P+ N
Functional group
PD
PD
PD
PD
PM
SOM
P
13.22
11.95
12.59
9.80
2.12
Positive
29.43
16.25
22.84
15.83
2.51
Negative
Cognitions (M)
.310
.424
.356f
.382
.458
P+ N
Dysfunctional group
NM
ND
ND
ND
IDC
SOM
α
States of mind (SOM): PM, positive monologue; PD, positive dialogue; IDC, internal dialogue of conflict; ND, negative dialogue; and NM,
negative monologue. The SOM proportion is represented by P/(P + N), the proportion of positive to total positive (P) plus negative (N)
cognitions. Only cases in italics were included in the statistical analyses; although informative, figures not italicized were not treated as
separate cases since they represent redundant data (see Schwartz & Garamoni, 1986a). Cases marked by a dagger (f) were classified as
moderately dysfunctional; unmarked cases were classified as mildly dysfunctional.
b
ASST, Assertiveness Self-Statement Test.
c
ASST-Revised generalizes to a broader range of assertion situations.
d
ASST-Negative and ASST-Positive tap cognitions in negative and positive assertion situations, respectively.
e
Scores were averaged across high and low anonymity conditions.
'SISST, Social Interaction Self-Statement Test.
8
PVTR, Post-Performance Videotape Reconstruction.
h
"Positive recall" and "negative recall" scores were computed following Kuiper and MacDonald (1982).
1
Percentage of total memories associated to neutral words that were rated as having been happy or unhappy.
' Recall frequencies for positive and negative self-referent words.
k
SVQ, Self-Verbalization Questionnaire, assesses cognitions in situations with success and failure outcomes.
1
d' Value is a measure derived from Signal Detection Theory (SDT) that assesses recognition sensitivity for positive and negative words
and is free from response bias, criterion, or set (β).
Rychlak (1973), normal versus
abnormal adolescents
Study
Cognitive
assessment
method/
measure
TABLE II (Continued]
P
37
Study
Cognitive
assessment
method/
measure
Schwartz & Garamoni (1985), oral
hygiene students
5.6
2.6
4.1
Post
1 Month FU b
6 Months FU
Combined post
Pre
6 Weeks
Combined pre
Post
1 Month FU
6 Months FU
Combined post
.384
.228
.315f
.225f
.249
.202
"
P+ N
Stress management/health habit modification
Inventory/self28.9
33.2
.465
generated,
pre / post
9.0
8.8
8.9
14.8
4.3
Combined pre
Negative
14.5
15.0
Agoraphobia
Positive
Cognitions (M)
Pretreatment
4.8
3.8
Mavissakalian et α J. (1983), agoraphobic Production/
patients
talking aloud
Self-statement
Pre
training
6 Weeks
Paradoxical
intention
TABLE III
IDC
ND
NM
ND
NM
NM
NM
36.4
0.8
1.2
1.0
1.0
5.5
3.3
3.8
4.2
SOM Positive
22.7
0.8
1.0
0.4
0.7
3.0
3.0
1.8
2.6
Negative
Cognitions (M)
PD
IDC
IDC
PM
PD
PD
IDC
PD
PD
(continued)
.616
.500
.545
.714
.588
.647
.523
.679
.618
Ρ
P + N SOM
Posttreatment
States of Mind (SOM) and Associated P/[P + N) Proportions: Psychotherapy Outcome Studies0
38
Attribution
training
Derry & Stone ( 1 9 7 9 ) , nonassertive
students
Cognitive
self-statement
No-treatment
control
Placebo
(behavioral insight)
Craighead ( 1 9 7 9 ) , nonassertive female
students
Self-instructional
training
Study
Post
1 3 Weeks FU
Combined post
Post
1 3 Weeks FU
Combined post
Friends
Acquaintances
Combined
Friends
Acquaintances
Combined
Friends
Acquaintances
Combined
Inventory/ASSTC
7
1
9
7
6
.
.
.
.
.
3
8
6
4
2
4 0 . 0
4 8 . 7
4 4 . 4
4 6 . 8
4
5
4
4
4
2
6
9
4
1
.
.
.
.
.
0
5
3
4
7
.
.
.
.
.
4
5
5
4
4
7
2
0
6
7
6
7
2
6
2
6
0
8
5
7
.
.
.
.
.
9
5
7
4
7
0
1
1
7
6
4 7 . 0
5
5
5
4
4
.
.
.
.
.
3
9
1
5
5
4 5 . 0
4 6 . 5
4 5 . 8
5 6 . 6
5
6
5
5
5
7
2
5
0
6
4 8 . 2
4
4
4
5
4
4
2
3
1
8
.
.
.
.
.
.
.
.
.
.
8
7
8
1
3
7
5
1
2
1
5
5
5
4
5
6
6
6
5
5
1
5
3
8
0
2
4
3
7
4
. 4 9 4 *
.
.
.
.
.
.
.
.
.
.
3
0
1
6
2
1
9
5
4
4
IDC
IDC
IDC
IDC
IDC
IDC
PD
PD
PD
PD
IDC
4 4 . 7
. 5 5 9*
PD
4 8 . 9 . 4 7 9 IDC
4 6 . 0 . 5 0 3 IDC
4 7 . 5 .491*
IDC
3
3
3
4
4
Negative
P +^ N SOM
Posttreatment
Cognitions (M)
SOM Positive
IDC
IDC
IDC
IDC
IDC
5 3 . 1
. 4 6 8
IDC
5 2 . 0 . 4 3 5 ND
4 6 . 1 . 5 1 4 IDC
4 9 . 1 . 4 7 5 IDC
5
4
4
5
5
Negative
P +^ N
Pretreatment
Cognitions (M)
Positive
Assertiveness
Inventory/ASST cd
Cognitive
assessment
method/
measure
TABLE III (Continued)
39
Post
3 Months FU
Combined post
Post
3 Months FU
Combined post
Post
3 Months FU
Combined post
Post
3 Months F U
Combined post
Post
13 Weeks FU
Combined post
Inventory/ASST C
58.2
54.7
56.5
57.6
53.5
55.6
52.1
51.3
51.7
46.1
—
—
48.9
43.3
46.1
44.0
38.4
41.2
43.5
43.1
43.3
47.3
45.0
46.2
49.1
—
—
53.8
49.8
51.8
.569
.588
.578
.570
.554
.562
.524
.533
.528
.484e
—
—
.476
.465
.471*
PD
PD
PD
PD
IDC
PD
IDC
IDC
IDC
IDC
—
—
IDC
IDC
IDC
α
States of mind (SOM): PM, positive monologue; PD, positive dialogue; IDC, internal dialogue of conflict; ND, negative dialogue; and NM,
negative monologue. The SOM proportion is represented by P / ( P + N), the proportion of positive to total positive (P) plus negative (N)
cognitions. Only cases in italics were included in the statistical analyses; figures marked by an asterisk (*) represent posttreatment/followup data for ineffective interventions that were excluded from statistical analyses; also excluded were otherwise unmarked figures that
represent redundant (albeit informative) data (see Schwartz & Garamoni, 1986a). Pretreatment cases marked by a dagger (f) were classified
as moderately dysfunctional; pretreatment cases unmarked by (f) were classified as mildly dysfunctional.
b
FU, Follow-up.
c
ASST, Assertiveness Self-Statement Test.
d
Pre- and posttreatment assessments.
e
Treated as pretreatment data for mild dysfunctional group in statistical analyses.
Waiting list
control
Behavioral
rehearsal
Cognitive
self-statement
Valerio & Stone (1982), nonassertive
female students
Combined
treatment
Behavioral
rehearsal
40
Robert M. Schwartz and Gregory L. Garamoni
Taken together, these studies provided 63 independent sample cases
for analysis. To evaluate the major hypotheses, we first derived SOM
proportions and the SOM categories (PM, PD, IDC, ND, NM) for each
sample from reported mean frequencies of positive and negative cognitions. All samples were classified as either functional or dysfunctional.
Dysfunctionals were further subclassified according to level of disturbance as mildly or moderately dysfunctional. Assignments for group
contrast samples directly followed from a study's selection criteria (e.g.,
high versus low assertion, nondepressed versus depressed). In the psychotherapy outcome studies, pretreatment groups were classified as
dysfunctional, whereas posttreatment groups were classified as functional only if the intervention was potentially active and actually resulted in statistically significant improvement on relevant (noncognitive) self-report or behavioral measures. No-treatment, wait-listed,
placebo, and ineffective treatment groups were not accorded functional
status.
A. Set Points and Ranges
1. Positive Dialogue: A Functional SOM
Table IV summarizes the principal results of our analyses. The first
major hypothesis derived from the SOM model, that functional individuals engage in a PD, was supported. As expected, the mean SOM proportion for functional cases did not differ significantly from the cognitive affective set point of the PD. Moreover, the narrow 9 5 % confidence
interval around the mean SOM proportion indicated that the PD set
point represents a precise estimate of functional individuals' SOM.
Data shown in Table IV also indicate that the PD range captured the
actual SOM proportions exhibited by most functional individuals. The
theoretical PD range corresponded closely to an empirically derived
SOM range for the functional samples, defined by the mean plus or
minus one standard deviation. Moreover, the SOM proportions for
functional cases ranged from .528 to .768, with a substantial majority
(78%) falling within the PD range (see Fig. 3). Taken together, these
findings indicate that functional individuals tend to engage in an internal dialogue in which positive and negative cognitions are asymmetrically balanced according to the golden section.
2. Deviations from the Positive Dialogue: Dysfunctional SOMs
The model also specifies that dysfunctional individuals do not engage
in a PD, but exhibit an SOM that is either significantly above or below
the PD. Because none of the studies assessed individuals whose SOM
Mildly dysfunctional (22)
Moderately dysfunctional (9)
.500 ± .05
.382 ± .06
.374 ± .09
.489 ± .04
.455 ± .08
Internal
dialogue of
conflict
Negative
dialogue
.630 ± .06
Dysfunctional (31)
Obtained
values
(M ± SD)
Functional (32)
.618 ± .06
Positive dialogue
Comparisons
groups (n)
Theoretical
SOM ranges
State
of
mind
.307-.440
.470-.507
.427-.484
.609-.651
95%
confidence
interval
8
21
30
31
df
-0.29
-1.26
-11.63
1.16
t
Τ test
TABLE IV
Comparison of Theoretical and Obtained States of Mind (SOM) for Functional and Dysfunctional Groups
.781
.221
.0000
.255
ρ
Robert M. Schwartz and Gregory L. Garamoni
42
100
Upper L i m i t r- - , + 1 S D
.90
4 T P / (P+N)
S O M Set Point 4- !
L o w e r Limit L - - 1 S D
.80
.70
.60
I
PD
-M
-50
IDC
- .40
ND
.30
.20
.10
.00
Functional
Mildly
Dysfunctional
(Ν =32)
(N = 2 2 )
Moderately
Dysfunctional
(N = 9)
L e v e l of F u n c t i o n i n g
Fig. 3. Distribution of mean state of mind (SOM) proportions for functional and dysfunctional groups. The legend indicates the set points and ranges for the theoretical (solid
lines) and obtained (dotted lines) SOMs. P/(P + N) = the proportion of positive to total
cognitions.
would be expected to deviate in a positive direction from the golden
section (e.g., hypomanics, manies), the hypothesis tested was that dysfunctionals exhibit an SOM that deviates negatively from the
cognitive-affective set point of the PD. As predicted, the mean SOM
proportion for dysfunctional cases was significantly less than the PD set
point (see Table IV). Furthermore, the upper limit of the 95% confidence
interval for the dysfunctionals' mean SOM proportion fell well below
the PD set point.
The data also indicate that the PD range has discriminant validity.
The empirically obtained SOM range for dysfunctionals fell below the
PD range. Moreover, the SOM proportions for dysfunctional samples
ranged from .225 to .571, with all but one of the 32 cases (97%) falling
below the PD range (see Fig. 3). These findings demonstrate that dysfunctional groups — at least those drawn primarily from anxious and
depressive populations — engage in an internal dialogue (or monologue)
in which the proportion of positive and negative cognitions deviates in a
negative direction from the golden section.
43
States of Mind Model
3. internal Dialogue of Conflict: A Mildly Dysfunctional SOM
The model also predicts that the greater the deviation from the PD set
point, the more severe the pathology. Accordingly, it was specifically
hypothesized that mildly dysfunctional groups would exhibit an IDC,
whereas moderately dysfunctional groups would exhibit an ND. As
expected, the mean SOM proportion for mildly dysfunctional cases did
not differ from the cognitive-affective set point of the IDC (see Table
IV). Furthermore, the 95% confidence interval around the obtained
mean SOM proportion was narrow, indicating that the set point of the
IDC closely approximates the SOM expected of mildly dysfunctional
individuals.
The validity of the IDC range was also supported by the available data.
The empirically derived SOM range for mild dysfunctionals corresponded closely to the IDC range. Moreover, the SOM proportions
ranged from .400 to .571, with a substantial majority (77%) falling as
expected within the IDC range (see Fig. 3). These findings indicate that
mildly dysfunctional individuals engage in an internal dialogue in
which positive and negative cognitions are symmetrically balanced.
4. Negative Dialogue: A Moderately Dysfunctional SOM
Only nine cases were available to evaluate the prediction that moderately dysfunctional individuals engage in an ND. Nevertheless, the
mean SOM proportion for moderately dysfunctional samples did not
differ from the cognitive - affective set point of the ND (see Table IV).
The 95% confidence interval around the obtained mean SOM proportion, though wider than those computed for the PD and IDC, bordered on
the upper and lower limits of the ND range.
The data also supported the validity of the ND range. The empirically
derived SOM for moderately dysfunctional groups was comparable to
the theoretically derived ND range. The SOM proportions ranged from
.225 to .524, with a clear majority (67%) falling as expected within the
ND range (see Fig. 3). These findings suggest that moderately dysfunctional individuals engage in an internal dialogue in which positive and
negative cognitions are asymmetrically balanced according to the inverse of the golden section.
B. Validity Issues
Our analyses yielded no evidence of major confounds. First, we
wanted to determine whether the model was limited to specific disorders. Our analyses (Schwartz & Garamoni, 1986a) indicated that the
main SOM set point and range hypotheses were confirmed when ap-
44
Robert M. Schwartz and Gregory L. Garamoni
plied to both anxiety and depression. Moreover, as can be seen in
Tables II and III, SOM proportions for more narrowly defined groups
(nonassertion, social anxiety, agoraphobia, low self-esteem, etc.) indicate that the model applies to a variety of specific disorders.
An additional test of the strength of the relationship between SOM
and severity of depression was possible because all nine studies that
assessed depression-relevant cognitions employed the Beck Depression
Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The
hypothesis that severity of depression is inversely related to SOM was
evaluated by a correlational analysis of mean BDI and SOM scores for all
groups of nondepressed and depressed subjects. As expected, the correlation between these measures was highly negative [r (19) = — .833,
ρ < .001]. Thus, the lower the SOM, the more severe the depression.
Further research could determine whether SOMs are related to other
measures of psychological functioning (MMPI, ego strength, self-efficacy, etc.) and to physical health status.
We also wanted to identify potential confounds due to assessment
procedures. To address this issue, multiple methods of assessment are
needed (Meichenbaum, 1977; Kendall, 1983; Merluzzi et αϊ., 1981). Fortunately, the studies employed diverse cognitive assessment methods,
including endorsement inventories (e.g., Schwartz & Gottman, 1976;
Glass et αϊ., 1982), thought listing (e.g., Cacioppo, Glass, & Merluzzi,
1979), talking aloud (Mavissakalian et αϊ., 1983), postperformance videotape reconstruction (Hollandsworth et α]., 1979), free recall (Bradley &
Mathews, 1983), recognition recall (Dunbar & Lishman, 1984), and free
association (Rychlak, 1973). Our analysis indicated that the pattern of
results derived from the most restrictive assessment methods (e.g., endorsement inventories) was comparable to that obtained from the least
restrictive methods (e.g., free association). Taken together, these findings represent converging evidence of the model's multibehavior-mul2
timethod validity (cf. Schwartz & Garamoni, 1986b).
2
Glass and Arnkoff (1982) suggested that endorsement inventories, such as the Assertiveness Self-Statement Test (Schwartz & Gottman, 1976) and the Social Interaction SelfStatement Test (Glass et ai., 1982), that ask the person to indicate how often a thought
occurred may measure the importance of the thought rather than its frequency. However,
production measures that more directly and unequivocally assess frequency, such as
those used by Rychlak (1973) and Mavissakalian et al. (1983), result in SOM proportions
parallel to those obtained with the inventory approach. Thus, both inventory and production methods of cognitive assessment appear to provide a valid and meaningful index of
the balance between positive and negative cognitions.
45
States of Mind Model
VI. DIRECTIONS FOR CLINICAL RESEARCH AND PRACTICE
Although the research reviewed in Section V provides initial support
for the model, a more extensive evaluation awaits additional research.
Explicit tests of the major hypotheses in controlled studies represent an
obvious starting point. Here we elaborate on salient methodological and
theoretical issues and suggest avenues for future research.
A. Implications for Assessment
1. SOM Set Points and the Positive-Negative Continuum
The positive-negative dimension has traditionally been viewed as a
variable that has a simple linear relationship with indexes of psychological functioning, such that more positivity implies better, and more
negativity implies worse. The present model clearly questions this assumption. Instead, the model postulates that there is a specific value
(.618) or range of values (.56 to .68) that represents an optimal balance of
positivity. Accordingly, values falling within the PD range are optimally
functional; sustained deviations above the upper limit or below the
lower limit of the PD range are dysfunctional. Thus, the present conceptualization of optimal balance implies that there is a curvilinear rather
than a linear relationship between the SOM variable and indexes of
psychological functioning.
A related issue concerns the nature of the theoretical distribution of
SOMs for the general population. The model implies that SOM proportion scores will not be distributed normally. Instead, individual scores
are expected to cluster around .382, .500, and .618, the three cognitiveaffective set points that define, respectively, the ND, IDC, and PD.
Therefore, the modal SOM proportion score in the general population
distribution should approximate the PD set point, with additional clustering around the set points for the IDC and ND. Drawing on data used in
the analyses summarized above (also see Schwartz & Garamoni, 1986a),
Fig. 3 depicts the distribution of SOMs for the 63 samples by level of
functioning. As can be seen, this hypothesized clustering occurred most
clearly at .62 for functionals and at .50 for mildly dysfunctionals. Too
few moderately dysfunctional samples were available to detect any
clear pattern of clustering.
Although these patterns and the analyses presented earlier are consistent with this hypothesis, the available data do not permit a full
resolution of this issue. Several studies selected and classified subjects
based on extreme scores on classificatory variables, thereby excluding
middle group subjects. Thus, the classification of groups as functional or
46
Robert M. Schwartz and Gregory L. Garamoni
dysfunctional may represent an artificially created separation that
could have obscured the true distribution of scores. Conceivably, this
methodological artifact might account for clustering in the data, but it
would not explain why the clustering occurred specifically around the
theoretical set points. Neither could this rival explanation account for
the clustering of scores around .618 that was repeatedly demonstrated
in the golden section studies, which sampled presumably normal
populations — without using predefined groups. Moreover, in the
present data set, subjects were not excluded in categorizing groups as
mildly or moderately dysfunctional, and related analyses revealed little
overlap in the distribution of scores for these groups, a finding that is
consistent with the hypothesized clustering around the set points. In
any event, the issue of whether SOMs are normally distributed along a
continuum or cluster around the hypothesized set points can be resolved only with further study of the distribution of SOMs within entire
populations rather than in predefined groups (S. Shiffman, personal
communication, October 9, 1984).
2. Bidimensional Assessment
The present formulation and the supporting data summarized in Section V underscore the potential value of including a bidimensional assessment of cognition and affect in future research. Rather than focusing
exlusively on the negative dimension (e.g., dysfunctional attitudes:
Beck, 1976; Weissman, 1979) or the positive dimension (e.g., optimism:
Scheier & Carver, 1983), such variables can be conceptualized as bidimensional structures consisting of both elements. As more studies include a bidimensional assessment of cognition, we will be better able to
understand the nature and function of the various SOMs and the issue of
optimal cognitive-affective balance.
Assuming that both dimensions are included, how shall they be
treated in analyzing and reporting data? Meichenbaum (1977) observed
that because people engage in both types of thinking, a weighted average
reflecting their combined influence may be the most sensitive measure
of the internal dialogue. However, studies that employed bidimensional
assessment have opted for different strategies with no unifying rationale. Different approaches include scoring and analyzing each dimension separately (Glass et al, 1982; Schwartz & Gottman, 1976), calculating a simple difference score by subtracting negative from positive
(Kendall et αϊ., 1979; Missel & Sommer, 1983), adding a constant to the
difference score (Bruch, Juster, & Kaflowitz, 1983), and presenting simple ratios of positive to negative (Hollandsworth et αϊ., 1979; Schwartz,
1986). Although various weighted or unweighted combinations of posi-
States of Mind Model
47
tive and negative scores may have specific applications, the diverse
approaches cited above suggest that we may be headed toward a 'Tower
of Babel" in presenting positive - negative cognition data.
The present formulation indicates that future research should report
the SOM proportion as well as the positive and negative dimensions.
Unlike the various measures mentioned above, the SOM variable is a
measure of a specific theoretical construct — state of mind—that is
rationally derived from information-processing principles and is empirically anchored in research on social and clinical cognition. If routinely
included in clinical research, this measure would facilitate comparisons
across studies of cognitive and affective dimensions of psychopathology
and psychotherapy, and maintain consistency with the growing research on the golden section (cf. Hollon & Kriss, 1984).
B. Research and Clinical Issues
1. Situational Determinants
The SOM model embraces the cognitive-behavioral assumption that
situational factors influence what people think. Although a given SOM
may predominate, SOMs will also fluctuate in response to situational
factors. The model does not hold that functional individuals maintain a
PD regardless of circumstances; nor is it expected that dysfunctional
individuals exhibit only one SOM across all situations. The hypothesized situational reactivity of SOMs is illustrated by studies that include
assessments of self-statements in response to both positive and negative
situations (Missel & Sommer, 1983; Pitcher & Meikle, 1980)
As can be seen in Table II, assertives exhibited a PD and nonassertives
an IDC in all group contrast studies that assessed cognitions only in
response to negative situations, such as unreasonable requests (Bruch,
1981; Klass, 1981; Schwartz & Gottman, 1976). In the one study (Pitcher
& Meikle, 1980) that reported cognitions in response to positive situations (e.g., compliments) as well as negative situations, our analyses
indicated that SOMs in both functional and dysfunctional groups fluctuated in response to situational parameters: Assertives responded to
negative situations with a PD, but to positive ones with a PM; nonassertives responded to negative situations with an IDC, but to positive situations with a PD.
Situational reactivity of SOMs is also apparent in Missel and Summer's (1983) study of depressed and nondepressed inpatients' thoughts
in depression-relevant situations. In each of 19 imaginai situations presented once with a positive (success) and again with a negative (failure)
outcome, subjects endorsed a positive self-verbalization, a negative
48
Robert M. Schwartz and Gregory L. Garamoni
self-verbalization, or an external attribution. Across the combined set of
success and failure situations, the derived SOM proportions revealed
predictable SOM differences between depressives (.34; ND) and nondepressives (.65; PD) (see Table II). A separate analysis by type of situation
revealed that SOMs in both groups varied as a function of the valence of
outcome: Depressives' SOM proportion was .43 (ND) in response to success, but .23 (NM) to failure; nondepressives' SOM proportion was .73
(PM) in response to success, but .56 (PD) to failure. Thus, SOMs in both
groups were influenced in part by situational factors—specifically the
positive (success) or negative (failure) valence of these imaginary situations.
2. Cognitive Content-Speci/icity
The model holds that SOMs are not only situationally specific, but
also content-specific. Here the source of influence is not an objective
parameter of a discrete event or ongoing situation, but rather a dimension of the contents of cognition itself. The importance of "ideational
content" has been stressed by Beck (1976, 1984), who argued that "the
key differences among the neuroses are revealed in the content of the
aberrant thinking rather than in its form" (p. 82). For example, Beck
stated that the thought contents of depressed, manic, and anxious patients centered on themes of loss, gain, and danger, respectively. Studies that employed psychiatric controls illustrate this point (Derry &
Kuiper, 1981; Missel & Sommer, 1983).
In Missel and Summer's (1983) study, the control group was composed
of nondepressed psychiatric inpatients, who exhibited a functional
SOM (PD) despite their disorder (see Table II). This finding may be
explained in terms of the sample of self-verbalizations represented on
the endorsement inventory: depressive cognitions in depression-relevant situations. If the situations and cognitions on the inventory had
been selected specifically for their relevance to this inpatient group's
psychopathology, predictable deviations from the PD might have been
observed.
Similarly, Derry and Kuiper's (1981) findings supported their "content-specificity hypothesis" that depressives have a self-schema specific
to depressed content. Our analysis of their data revealed that SOM
proportions for depressives, nondepressed inpatients, and nondepressed normals fell in the ranges for the ND, PD, and PM, respectively,
again suggesting that SOM differences among groups are content-specific. The pattern evident in both studies indicates that an adequate
cognitive assessment strategy must consider content categories in
studying the relationship between SOMs and different forms of psychopathology.
49
States of Mind Model
3. Temporal Stability
SOMs may also vary from one moment to the next. The issue of
temporal stability of SOMs is illustrated by Clark and Teasdale's (1982)
study, which investigated within-subject variability in associative recall for happy and sad experiences in depressed inpatients with diurnal
mood variation. On separate occasions when more and less depressed,
patients were asked to associate memories to a series of neutral words.
Based on their data, the derived SOM proportions fluctuated from .580
(PD) when they were less depressed to .422 (ND) when more depressed
(see Table II). These results suggest that the balance of positivity in
associative recall—and by implication in the internal dialogue — can
exhibit considerable temporal variability. To demonstrate this point, we
are currently conducting a study in which individuals with unipolarspectrum disorders are expected to exhibit more day-to-day stability in
their SOMs than will those with bipolar-spectrum disorders.
A related hypothesis is that the three dialogic SOMs, which have
cognitive-affective set points, are more temporally stable than the two
monologic SOMs, which lack set points. Evidence bearing on this hypothesis could be obtained by comparing SOMs on measures of t e s t retest reliability. Furthermore, within each dialogic SOM there should
be greater stability in the SOM proportion the closer it initially is to the
set point. It should also be more difficult to experimentally induce subjects through persuasion or feedback to move away from a set point than
toward it.
4. Cultural and Developmental
Factors
Cultural and developmental factors constitute additional sources of
influence on SOMs. That SOMs are shaped by cultural factors is suggested by our analysis (see Table II) of the data presented by Glass et αϊ.
(1982, Table 1, p. 44). Based on Bern's Sex Role Inventory, male and
female subjects were classified as androgynous, masculine, feminine, or
undifferentiated. Calculating SOM proportions based on cognitive data
derived from the Social Interaction Self-Statement Test, we found that
masculine subjects of both sexes most closely approximated the PD set
point (females = .611; males = .597). This finding is consistent with the
results of a recent meta-analysis of congruency, androgny, and masculinity models of sex role identification (Whitley, 1983), which revealed
that masculine role identity was more strongly associated with measures of well-being than the other two patterns of identification.
Our analyses of data from Glass et αϊ. (1982) also indicate that females,
regardless of sex role classification, fell within the PD range
(androgynous = .594; feminine = .557; undifferentiated = .576). In
50
Robert M. Schwartz and Gregory L. Garamoni
contrast, only the masculine males fell in the PD; all other males were in
the IDC (androgynous = .528; feminine = .497; undifferentiated =
.445). This pattern of results indicates that females may have somewhat
greater latitude than males in sex role identification while still maintaining a PD during social interactions; for males, the path to healthy
mindedness in this domain is narrow indeed.
Evidence that SOMs vary from one culture to another is currently
lacking. Findings from golden section studies indicate that SOM proportions approximate the PD set point in presumably normal samples
drawn from Canada (e.g., Benjafield & Adams-Webber, 1976), England
(Benjafield & Green, 1978), Sweden (Shalit, 1980), Trinidad (Romany &
Adams-Webber, 1981), and the United States (Rigdon & Epting, 1982).
Clearly, studies of SOMs across more heterogeneous cultural (or subcultural) groups and various content domains are needed to adequately
address this general hypothesis.
Viewed within the framework of the present model, Rychlak's (1973)
findings suggest that both developmental and social factors influence
SOMs. We found that the only divergence from the PD set point for the
functional group was the SOM proportion of .896 in the category of
future content, which was much higher than those for other content
categories, including past content (.616), images (.648), and ideas (.583)
(see Table II). This finding may be attributed to certain sample characteristics: The subjects, who were 15- to 18-year-old males attending a
private preparatory school, came from upper class backgrounds with
fathers holding such positions as stock market analyst, diplomat, and
corporate president. These developmental and socioeconomic factors
may explain why this group of well-situated normal adolescents —
when unconstrained by present or past reality — "think positively" into
the future (Rychlak, 1973). Future-oriented positive monologues may
indeed be age and SES appropriate.
Consistent with this interpretation, golden section studies indicate
that children become progressively "less lopsided" in their use of positive relative to negative construct poles (Applebee, 1 9 7 5 , 1 9 7 6 ; Barratt,
1977; Romany & Adams-Webber, 1981). For example, Romany and
Adams-Webber (1981) found in their study with Canadian and Trinidadian children that 10 year olds exhibited a higher mean SOM proportion than did 14 and 15 year olds (.70 versus .62). Apparently, young
children acquire positive constructs earlier than negative ones (Boucher
& Osgood, 1969), become progressively less positive over time, and stabilize at the PD set point during mid-adolescence. Also relevant here are
Rychlak's (1973) findings (discussed above), which suggest that the future time perspective may be the last to become more balanced with
negativity. This account is consistent with recent developmental
States of Mind Model
51
theories that highlight the increasing need for awareness and acceptance of limitations at successive stages of development (Erikson,
1 9 5 0 / 1 9 6 3 ; Levinson, Darrow, Klein, Levinson, & McKee, 1978).
5. Psychotherapy and SOMs
The few psychotherapy outcome studies that utilized bidimensional
assessment reveal patterns that demonstrate the utility of tracking
changes in SOMs as a function of therapy. Inspection of Table III indicates that all pretreatment SOM proportions were predictably outside
the PD range, falling in either the IDC (four), ND (one), or NM (one).
Thus, negative deviations from the PD set point are associated with
therapy-seeking. Moreover, four of the posttreatment means fell within
the PD range, whereas two fell in the IDC, indicating that the effects of
psychotherapy are typically accompanied (if not mediated) by a shift
toward healthy mindedness.
For each psychotherapy outcome study, Table III orders the interventions from most to least effective as determined by the outcome criteria
used in the study. The derived SOM proportions for two of the nonassertion intervention studies (Craighead, 1979; Valerio & Stone, 1982) indicate that the more effective the treatment, the more consistently the
posttreatment SOM fell in the PD range. However, in the third study
(Derry & Stone, 1979) all three treatment groups achieved only an IDC,
although the most effective one (cognitive self-statement) resulted in an
SOM proportion (.550) that was just below the lower limit of the PD at
follow-up. This study involved two sessions, the first consisting of 30
minutes of behavioral rehearsal, and the second 40 minutes of cognitive
self-statement training—hardly adequate to achieve substantial cognitive restructuring. That there were significant improvements on other
self-report measures of assertiveness and overt behavior raises the general issue of desynchrony among domains of functioning, and the specific question of why cognitive change in some cases may lag behind
behavioral change.
The Mavissakalian et al. (1983) treatment study illustrates the value
of using repeated measures to track SOMs throughout the course of
treatment. Agoraphobics were provided with 6 weeks of either paradoxical intention therapy (PI) or self-statement training (SST). Our analysis of their data indicates that the pretreatment SOM proportions for
the PI and SST groups were in the ND and the NM ranges, respectively
(see Table III). The PI group — the more effective therapy in the short
run — progressed from a pretreatment ND to an IDC at immediate posttreatment, maintained an IDC at 1 month follow-up, and then reached a
PM at 6 months follow-up. The average of the three posttreatment measures was .588, which was within the PD range. The SST group pro-
52
Robert M. Schwartz and Gregory L. Garamoni
gressed from a pretreatment NM to a PD at immediate posttreatment,
regressed to an IDC at 1 month follow-up, and then rebounded to a PD at
6 months follow-up. The average of these three posttreatment measures
was .618, the "golden number" to the thousandth.
Since the SST patients were close to the PD set point at posttreatment,
what accounts for the subsequent regression to an IDC 1 month after
therapy was terminated? The oscillating trends in this group may be
explained by the fact that cognitive restructuring is a gradual process
that requires time for the modification and integration of new cognitive structures (Goldfried & Robins, 1983; Hollon & Kriss, 1984). Because
separation issues are associated with agoraphobia (Guidano & Liotti,
1983), termination of therapy may have threatened the integrity of these
patients' newly acquired cognitive structures, resulting in the temporary regression to a conflicted SOM 1 month following treatment. Over
time and with continued mastery, these structures were presumably
consolidated. The central tendency of this constructive process over the
6-month period is toward the PD set point of .618, but on any given day
there may be fluctuations above and below this value.
Thus, rather than simply revealing whether measures of cognition
and affect change significantly from pre- to posttreatment, the SOM
model permits stronger tests of the intervention, viz. how closely the
posttreatment SOM approximates the PD set point. The model also provides for a descriptive perspective on SOM fluctuations throughout and
after treatment rather than just a quantitative assessment of degree of
positivity. Finally, the optimal balance hypothesis implies that excessive positivity (PM) as a result of therapy would represent an unstable
SOM that leaves the client potentially vulnerable to relapse.
6. SOM and Modes of Information Processing
Cognition is an umbrella term that encompasses a complex set of
processes (Kuiper & MacDonald, 1983). For instance, Neisser (1967) used
this term to refer to "all the processes by which the sensory input is
transformed, reduced, elaborated, stored, recovered, and used. Such
terms as sensation, perception, imagery, retention, recall, problemsolving, and thinking, among others, refer to hypothetical stages or
aspects of cognition" (p. 4).
Viewing cognition within the framework of a stage or phase model
implies that the internal dialogue is simultaneously or sequentially
subserved by multiple cognitive functions (cf. Erdeyli, 1974; and Matlin
& Stang, 1978, for the heuristic potential of a multistage model of information processing). This perspective raises the general issue of whether
the SOM model can be generalized to various modes of information
processing.
States of Mind Model
53
Of the 27 studies we reviewed, 18 assessed positive and negative
self-statements in response to specific situational stimuli. Thus, the
primary source of support for the model derives from situationally specific internal dialogues. Also consistent with the model's predictions
were the results of the remaining nine studies that assessed other cognitive constructs, including free association (Rychlak, 1973) and memorybased (schematic) processing (e.g., Derry & Kuiper, 1981). Comparing
SOM proportions for these constructs, we found no differences between
the balance of positive and negative information processed in short- and
long-term memory/imagination and that observed in the internal dialogue (Schwartz & Garamoni, 1986a).
In the first of the depressive self-schema investigations, Derry and
Kuiper (1981) assessed differences in self-schema content among depressed patients, nondepressed psychiatric controls, and nondepressed
normals. The subjects rated whether depressed- and nondepressedcontent adjectives were self-descriptive, and then recalled as many of
these adjectives as possible. Results indicated that depressives displayed enhanced recall for self-referenced, depressed content, whereas
both normals and psychiatric controls demonstrated recall superiority
for self-referenced, nondepressed content. Thesefindingssupported the
hypothesis that depressives have a negative self-schema—a cognitive
structure of predominantly negative content that increases retention of
any new information consistent with this stored body of self-knowledge.
Within the framework of the present model, we expected that the
pattern of SOM proportions for self-referenced memories in Derry and
Kuiper's (1981) study would parallel those obtained for situationally
specific self-verbalizations in Missel and Summer's (1983) study (SOM
proportions: nondepressives = .648, depressives = .340). We found that
the proportions of scores for positive to total self-referent recall for
nondepressed normals, nondepressed psychiatric inpatients, and depressed inpatients were .714 (PM), .585 (PD), and .333 (ND), respectively
(for a discussion of "recall scores," see Kuiper & MacDonald, 1982).
Thus, nondepressives and depressives exhibit quite similar differences
in SOM proportions when assessed both in terms of a situationally anchored internal dialogue and in terms of short-term memory for self-referent information.
Variations in Derry and Kuiper's (1981) schematic processing paradigm have been successfully employed in other depression studies
(Bradley & Mathews, 1983; Clark & Teasdale, 1982; Dunbar & Lishman,
1984; Dyck, Erdile, Herbert, & Hewitt, 1983; Kuiper & Derry, 1982;
Kuiper & MacDonald, 1982). In general, our analysis (Schwartz & Garamoni, 1986a) of the results of these studies indicates that self-referent
information is remembered in a proportion that falls within the PD in
54
Robert M. Schwartz and Gregory L. Garamoni
nondepressives, the IDC in mildly depressed college students, and
the ND in moderately depressed patients. As can be seen in
Table II, the same pattern of memory-based SOMs was obtained for
self-referent information available from short-term (e.g., Kuiper &
Derry, 1982) and long-term memory (e.g., Clark & Teasdale, 1982). Moreover, this same pattern is evident in studies that assessed recognition
(Dunbar & Lishman, 1984) and recall memory (e.g., Bradley & Mathews,
1983).
Thus, the SOM proportion observed in the internal dialogue may
reflect in part the balance of positive and negative information available
from short- and long-term memory. In light of these studies, we offer the
more general hypothesis that the SOM proportion indexes a pervasive
principle that regulates the balance of positivity processed in a variety of
"cognitive tributaries" that "feed into the stream of consciousness" and
ultimately constitute the internal dialogue.
VII. CONCLUSION
We conclude this presentation of the structural model of positive and
negative states of mind by placing it in the more general context of
related cognitive theories. Earlier cognitive-dynamic or balance
theories, such as those developed by Heider (1958) and Festinger (1957),
postulated a drive reduction toward cognitive consistency (consonance,
congruity), which results in the resolution of cognitive stress (Osgood &
Richards, 1973). Balance in these approaches is thus equated with the
elimination of inconsistencies. Heider (1946), for example, stated:
A balanced state exists if all parts of a unit have the same dynamic character (i.e., if all
are positive or all are negative), and if entities with different dynamic character are
segregated from each other. If no balanced state exists, then forces towards this state
will arise, (p. 39)
In contrast to the consistency approaches, optimal incongruity
theories (cf. Deci, 1975) postulate that individuals are intrinsically motivated to seek an optimal level of incongruity, discrepancy, or psychological complexity (e.g., Berlyne, 1969; Hunt, 1965; McClelland, Atkinson,
Clark, & Lowell, 1953; Walker, 1973). As Deci (1975) observed, Hunt
(1965) developed this idea into a general theory that considers intrinsic
motivation toward optimal incongruity as inherent in information processing and human action. The essential point is that intrinsically motivated behaviors will be initiated when there is a discrepancy between
the existing amount of incongruity in a system and some standard or
required level of optimal incongruity.
55
States of Mind Model
The present SOM model clearly stands in the tradition of such optimal
incongruity theories. Because a dialectical view is fundamental, the
goal is not the segregation of conflicting elements, but rather the attainment of an asymmetrical balance or harmony of these opposing features
proportioned according to the golden section ratio — the standard of
optimal incongruity. As we have seen, the complete segregation of positive and negative elements (i.e., positive and negative monologues) represents pathological adaptation, not states toward which the individual
normally strives. Instead, healthy mindedness is defined by the golden
dialogue: a state of mind containing an optimal incongruity, or tensive
relationship, between the fundamental polarities of positive and negative cognition and affect.
We observed earlier that although symmetry has traditionally been
assumed to underlie the structure of physical and psychological reality,
more recent scientific evidence reveals a variety of important asymmetrical relationships. In the sphere of ethics, this historic reverence for
symmetry led to the Pythagorean maxim "Step not beyond the center of
the balance" (Wheelwright, 1960, p. 227). Aristotle also drew upon the
concept of symmetry in emphasizing the importance of adhering to the
golden mean, which he identified as the point equidistant from the
extremes. The structural model of positive and negative states of mind
and the supporting evidence suggest a small, but decisive revision — the
golden mean appears to be asymmetrically rather than symmetrically
balanced. With this qualification, the ancient wisdom may survive the
test, not only of time, but of scientific research as well.
ACKNOWLEDGMENTS
The authors thank Judy Grumet, Philip Kendall, and Richard Moreland for their useful
comments on the manuscript, and John Close for his assistance in analyzing data. We also
wish to thank all of the investigators who provided us with additional information regarding their research.
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Rationality Revisited: A Reassessment
of the Empirical Support for the
Rational-Emotive Model
TIMOTHY W. SMITH AND KENNETH D. ALLRED
Department of Psychology
University of Utah
Salt Lake City, Utah 84112
I. Introduction
II. Assessment of Irrational Beliefs
A. The Problem of Discriminant Validity
B. New Developments in Assessment
III. Irrational Beliefs and the Arousal of Distress
A. The Dysphoria Confound in Simple
Correlational Studies
B. Manipulation of Rational versus Irrational
Thought Content
C. Studies of Laboratory Stressors
D. Irrationality, Life Events, and Distress
IV. Irrational Beliefs and the Process of
Therapeutic Change
V. Conclusions: Continued Complaints and
Lingering Limitations
References
63
65
66
69
71
71
73
74
77
79
81
83
I. INTRODUCTION
The rational-emotive model of emotional dysfunction and psychotherapy continues to be a major, vital force in clinical and counseling
psychology. For 25 years, Albert Ellis's now classic approach has been
viewed as interesting, useful, and controversial. In both popular and
professional audiences, the simple proposition that irrational beliefs
mediate the relationship between environmental events and psychological difficulties has met with acceptance and skepticism, but rarely
indifference. The corollary to this assumption, that changes in such
ADVANCES IN COGNITIVE-BEHAVIORAL RESEARCH
AND THERAPY, VOLUME 5
63
Copyright © 1986 by Academic Press, Inc.
All rights of reproduction in any form reserved.
64
Timothy W. Smith and Kenneth D. Allred
beliefs produced by various therapy techniques result in corresponding
changes in emotional distress, has been a major impetus to the current
cognitive Zeitgeist in psychotherapy theory and practice.
In addition to the appealing simplicity of rational-emotive therapy
(RET), one of its major attractions has been its apparent accessibility to
empirical evaluation. Unlike many of its predecessors, the central concepts of the ABCD model (activating events, irrational beliefs, emotional
consequences, and therapeutic dispute of beliefs) promised to be relatively easily quantified (Ellis, 1962). A parsimonious, empirically testable model of adjustment and behavior change was then and remains
now a valuable commodity. Although many individuals have criticized
more recent presentations of the RET model (e.g., Ellis, 1977) for its
conceptual imprecision (Ewart & Thoreson, 1977; Eschenroeder, 1982;
Mahoney, 1977a; Meichenbaum, 1977), the model has been the basis for
a substantial amount of research. The interpretation of this literature,
however, is another matter. Not surprisingly, reviews by proponents of
RET have offered the conclusion that the model is well grounded empirically (Ellis, 1977). Such conclusions have been criticized as reflecting at
least a confirmatory selectivity, and perhaps even a serious misunderstanding or misinterpretation of the results of many studies (Ewart &
Thoreson, 1977; Mahoney, 1977a; Meichenbaum, 1977).
The combination of a popular, influential, and controversial theory
and pointed disagreement over the interpretation of a large body of
empirical findings prompted Smith (1982) to undertake a systematic
review of this literature. Although few disconfirming findings were
noted and many studies were consistent with the RET model, many
methodological problems, gaps in the empirical support, and conceptual
issues precluded definitive conclusions. The validity of existing measures of irrationality remained unproven. Tests of the mediational role
of irrational beliefs in emotional distress relied extensively on very
limited methodologies. Those employing more sophisticated approaches often produced conflicting results. While the data suggested
that RET was an effective treatment, little evidence existed as to the
process of these changes. Running throughout these empirical problems
were conceptual difficulties surrounding the key RET concepts. Given
this state of affairs, a call was made for renewed empirical scrutiny of
this influential theory.
In the time since that review many new findings have emerged. The
purpose of this article is to reassess the empirical support for the RET
model in light of these new results. We will emphasize the work from
our own laboratory, but include all major studies. As in the earlier
review by Smith (1982), we will focus on the assessment of irrational
beliefs, the role of irrational beliefs in the arousal of distress, and the
Rationality Revisited
65
effectiveness and process of RET. Like the previous review, it is our
conclusion that the degree of support for basic hypotheses of the model
is not consistent with the popularity and purported effectiveness of the
therapeutic procedures. Recent evidence suggests that existing measures of irrational beliefs may be seriously inadequate. These problems
with measurement render much of the empirical evidence indicating a
relationship between beliefs and distress open to alternative interpretations. Other recent tests of this relationship have not been supportive.
Finally, little evidence exists regarding the model's explanation of therapy process. Rational-emotive therapy seems to work, but it may not
provide an accurate description of why people have emotional problems
or how they improve in therapy. Existing research cannot justify more
definitive conclusions. Thus, an attractive degree of simplicity and effectiveness exists to support those who employ these therapy techniques and those who encourage others to do so, but nagging questions
remain to reinforce skeptics and motivate researchers.
II. ASSESSMENT OF IRRATIONAL BELIEFS
At the core of many of the troubling aspects of this literature are issues
of assessment. The RET model maintains that irrational beliefs mediate
the relationship between external events and subsequent distress. It
also maintains that changes in these beliefs mediate the therapeutic
alteration of distress.
At least 15 scales currently exist that purport to measure Ellis's (1962)
set of irrational beliefs (see Sutton-Simon, 1981, for a review). The majority of these scales have received limited use and little, if any, psychometric evaluation. The most widely used and thoroughly evaluated are
the Jones (1968) Irrational Beliefs Test (IBT) and the Shorkey and Whiteman (1977) Rational Behavior Inventory (RBI). Both of these self-report
inventories consist of many individual items which are combined to
form scores for individual irrational beliefs. The separate belief scores
are, in turn, combined to generate a score for total irrationality (IBT), or
rationality (RBI). The original reports on the RBI and IBT provided sufficient documentation of the internal consistency and temporary stability
of the tests, although a modified scoring system that enhances internal
consistency of individual belief scales has been suggested for the IBT
(Lohr & Bonge, 1982a). The convergent validity of these scales is demonstrated by the fact that they correlate with each other at approximately
.70 in both normal (Ray & Bak, 1980; Smith & Zurawski, 1983) and
clinical populations (Zurawski, Smith, & Johnson, 1985). Other evaluations of the construct validity of the RBI and IBT have involved correla-
66
Timothy W. Smith and Kenneth D. Allred
tions of these scales with measures of emotional distress. These correlations are routinely significant and will be reviewed in the discussion of
the empirical support for the hypothesis that beliefs mediate the arousal
of distress.
A. The Problem of Discriminant Validity
Lacking from the psychometric evaluations described above are evaluations of discriminant validity (Campbell & Fiske, 1959). While measures of irrational beliefs should correlate with measures of distress,
they should not correlate so highly with them as to be indistinguishable.
That is, a given measure of irrational beliefs should correlate, as predicted by the theory, with measures of distress, but not as highly as it
correlates with a second measure of irrational beliefs. The lack of discriminant validity demonstrated by measures of seemingly separate
traits (e.g., anxiety and depression) has been documented extensively
(Gotlib, 1984; Watson & Clark, 1984).
Smith and Zurawski (1983) examined this issue by comparing correlations among the RBI, IBT, and several measures of anxiety. A sample of
142 male and female college students completed the RBI and IBT, along
with the trait form of the State-Trait Anxiety Inventory (Spielberger,
Gorsuch, & Lushene, 1970), the Test Anxiety Inventory (Spielberger,
1980), the Fear of Negative Evaluation Scale (Watson & Friend, 1969),
and the Cognitive-Somatic Anxiety Scale (Schwartz, Davidson & Coleman, 1978). Pearson correlation coefficients are presented in Table I.
Tests of the significance of the differences between correlations revealed that the correlation of the RBI total score with the IBT total score
was significantly larger than the correlation of the RBI with each mea-
TABLE I
0
Correlations between Measures of Irrational Beliefs
b
and Measures of Trait Anxiety
C
IBT
RBF
RBI
STAI
TAI
FNE
CTAS
STAS
66
68
49
51
51
57
54
60
50
38
36
α
All p's < .001; η = 142. Decimals are deleted.
IBT, Irrational Beliefs Test; RBI, Rational Behavior Inventory (scoring reversed); STAI,
State-Trait Anxiety Inventory; TAI, Test Anxiety Inventory; FNE, Fear of Negative Evaluation; CTAS, Cognitive Trait Anxiety; STAS, Somatic Trait Anxiety. From Smith and
b
Zurawski (1983).
c
Scoring for the RBI is reversed so that higher scores equal more irrationality.
Rationality Revisited
67
sure of anxiety. Thus, the RBI demonstrated some degree of both convergent and discriminant validity. In contrast, the correlation between
the RBI and IBT was larger than only the IBT's association with test
anxiety and somatic anxiety. Thus, the IBT could not be differentiated
from general anxiety, evaluative anxiety, or cognitive anxiety. As a
result, it could be suggested that the most widely used measure of irrational beliefs actually represents a measure of trait anxiety that emphasizes cognitive features of distress.
The Smith and Zurawski (1983) study had two major limitations.
First, the college student population obviously limits generalization to
the clinical populations of more immediate interest. Second, only anxiety measures were used. As mentioned above, measures of anxiety may
not be assessing a dimension different from that assessed by self-report
measures of depression. Most such inventories may assess general dysphoria (Gotlib, 1984), neuroticism, or negative affectivity (Watson &
Clark, 1984). Therefore, it seems important to assess the discriminant
validity of irrational belief measures relative to this more global dimension.
Zurawski et αϊ. (1985) administered the RBI and IBT, along with three
measures of anxiety [Taylor's (1953) Manifest Anxiety Scale; the IP AT
Total Anxiety Scale (Krug, Scheier, & Cattell, 1976); and the trait form of
the State-Trait Anxiety Inventory (Spielberger et αϊ., 1970)], two measures of depression [Beck's (1967) Depression Inventory; and Dempsey's
(1964) D30 Scale from the MMPI], and two measures of anger [the trait
form of the State-Trait Anger Scale (Spielberger, Jacobs, Russell, &
Crane, 1983); and the Anger Inventory (Novaco, 1975)], to 73 community mental health center outpatients. The patients all carried diagnoses
of anxiety disorders, dysthymic disorders, or adjustment problems; no
psychotic patients or substance abusers were included. Pearson correlation coefficients among the scales administered are presented in
Table II.
Consistent with the results of Smith and Zurawski (1983), the RBI and
IBT were highly correlated. They correlated equally highly, however,
with the measures of anxiety and depression and one of the measures of
anger. Because the correlation between the two measures of beliefs was
not larger than their correlations with distress, neither measure of irrational beliefs demonstrated discriminant validity. It is interesting to
note that there was little evidence of discriminant validity for the remaining measures. Thus, it could be argued that the majority of the
measures, including the irrational belief scales, assesses general dysphoria (Gotlib, 1984) or negative affectivity (Watson & Clark, 1984).
This finding is not surprising when one examines the content of IBT
items. Many of them are worded in terms of behavioral and affective
Timothy W. Smith and Kenneth D. Allred
68
TABLE II
0
Correlations among Irrational Belief Measures, Anxiety,
b
Depression, and Anger
2
1. IBT
C
2. RBI
3. TMAS
4. IP AT
5. STAI-T
6. BDI
7. D 3 0
8. STAS-T
9. AI
C
71
3
4
5
6
7
8
9
66
69
66
73
87
70
77
86
77
59
70
77
73
81
61
70
89
81
85
80
55
50
63
70
57
51
55
38
43
44
46
38
40
39
38
α
η = 73; all p's < .001. Decimals have been deleted.
IBT, Irrational Beliefs Test; RBI, Rational Behavior Inventory; TMAS, Taylor Manifest
Anxiety Scale; IP AT, Institute for Personality Assessment Total Anxiety; STAI-T, StateTrait Anxiety Inventory-trait form; BDI, Beck Depression Inventory; D30, Dempsey Depression Scale; STAS-T, State-Trait Anger Scale-trait form; AI, Anger Inventory. From
Zurawski, Smith, and Johnson (1985).
c
Scoring on the RBI is reversed so that higher scores equal greater irrationality.
b
responses to potentially stressful situations, rather tfyan the strictly cognitive content they are intended to reflect. Endorsement of the item
would imply the presence of a related belief, but its content is similiar to
simple measures of distress. For example, the Jones (1968) item, "I often
worry about how much people approve of and accept me" is logically
related to the belief in the necessity of approval, but its wording includes
reference to the affect (i.e., anxiety or worry) this belief is hypothesized
to produce. Thus, high positive correlations may be artifacts of similar
affective item wordings, a problem common in studies involving correlations of self-report scales (Nicholls, Licht, & Pearl, 1982).
It is troubling that the most widely used measures of irrational beliefs
appear to lack discriminant validity relative to measures of the dysphoric emotions that they, in theory, mediate. A large part of the empirical evidence for the RET model is based on simple correlations between
measures of beliefs and measures of distress. The Smith and Zurawski
(1983) and Zurawski et al. (1985) studies indicate that contamination of
both sets of measures by neuroticism or dysphoria, rather than the
hypothesized relationship between cognition and affect, is an at least
equally parsimonious explanation of such relationships. In Section III, A
we describe further analyses of the Zurawski et al. (1985) data to illustrate this point. For the time being, it should suffice to note that the need
for reliable and valid measures of the mediating congitive construct,
Rationality Revisited
69
essential for evaluating any cognitive-behavioral theory (Kendall &
Korgeski, 1979), apparently is not filled by the IBT, and perhaps not by
the RBI either. Thus, a conservative though most reasonable interpretation of this state of affairs suggests that tests of fundamental RET hypotheses must await more refined assessment techniques.
B. New Developments in Assessment
Several new trends may offer help in the task of assessing key concepts in RET. One avenue involves the assessment of beliefs in a limited
domain of functioning. For example, Eidelson and Epstein (1982) have
developed a measure of dysfunctional (i.e., irrational) beliefs about
relationships. These include the beliefs that (1) disagreement is destructive, (2) mindreading is expected, (3) partners cannot change, (4) one
must be a perfect sexual partner, and (5) the sexes are diametrically
different in their relationship needs. Initial results with this 60-item
scale seem to indicate that it is reliable and that it is correlated with
marital satisfaction; more relationship irrationality is associated with
reduced satisfaction. In a similar development, a measure of irrational
Type A beliefs has been developed. Based on previous findings indicating a relationship between IBT subscale scores and measures of Type A
behavior (Smith & Brehm, 1981), Thurman (1985) has developed a measure of the irrational beliefs he feels underlie the hard-driving, competitive Type A style. By focusing on specific beliefs, such new scales may be
able to avoid affective item content and the associated problem of discriminant validity.
Other approaches to cognitive assessment, though not intended to
assess Ellis's irrational beliefs per se, offer quite different solutions. The
problem of social anxiety provides a useful example. The RET model
maintains that individuals who experience severe anxiety in social
situations do so because they irrationally believe that it is essential that
others approve of them. The results of two recent studies are consistent
with this notion. Goldfried, Padawer, and Robins (1984) asked socially
anxious and nonanxious subjects to rate a variety of situations on a
number of semantic differential scales. Goldfried et αϊ. then subjected
the ratings to multidimensional scaling in an effort to define the cognitive dimensions used by the subjects in appraising situations. The results indicated that the possibility of being evaluated was an important,
often used dimension for socially anxious subjects; this dimension was
significantly less important for nonanxious subjects.
Using a completely different methodology, Smith, Ingram, and Brehm
(1983) found similar differences between socially anxious and nonanxious subjects. Smith et αϊ. employed the depth of processing paradigm
70
Timothy W. Smith and Kenneth D. Allred
(Craik & Tulving, 1975; Rogers, Kuiper, & Kirker, 1977) to assess cognitive activity of these two groups in socially threatening and nonthreatening situations. In the typical depth of processing experiment,
subjects are provided with a set of stimulus words and are asked to make
judgments about each word according to a specified "orienting task/'
The primary dependent measure is the number of words recalled in a
later incidental recall task for each kind of orienting task. The number of
words recalled, in turn, reflects the depth, level, or degree of processing
of the stimuli produced by a given orienting task. That is, orienting tasks
that require deeper, more involved processing of the stimulus word will
produce higher rates of recall. Smith et αϊ. (1983) used four types of
orienting taks: (1) structural ("Was the word read by a male or female
voice?"), (2) semantic ["Does the word mean the same as (opposite of)
?"], (3) private sel/-re/erent ("Does the word describe you?"), and
(4) public self-relevent ("Would someone who knows you or who had
just met you say that the word describes you?"). High and low socially
anxious subjects were defined by scores in the top and bottom quartiles
of a distribution of approximately 1000 scores on the Social Avoidance
and Distress Scale (Watson & Friend, 1969). The depth of processing task
was imbedded within an ostensible impression formation task. In a
group setting, subjects in the high stress condition were informed that
they would each be evaluated on a number of dimensions (i.e., poise,
intelligence, and attractiveness) after they individually stood in front of
the other subjects and described themselves. Subjects in the low stress
condition were told that the groups would make similar ratings of other
individuals, not present at that session, describing themselves on an
audiotape.
Means for state anxiety levels and the number of words recalled for
each level of processing are presented in Table III. The evaluative threat
manipulation was effective in that socially anxious subjects in the high
stress condition reported significantly more state anxiety than did the
other three groups of subjects. Analyses of the recall data indicated no
effects of social anxiety or stress on words processed with the structural,
semantic, or private self-referent task instructions. The predicted pattern was demonstrated for the public self-referent task. Socially anxious
subjects in the high stress condition recalled more words processed with
the public self-referent instructions (i.e., "Would someone who knows
you or who had just met you say that the word describes you?") than did
the other three groups of subjects. The results are consistent with the
prediction that socially anxious persons, when faced with evaluation,
display increased cognitive activity that reflects concern over evaluation of others.
Though they use very different methodologies, the Goldfried et αϊ.
Rationality Revisited
71
TABLE III
Self-Reported State Anxiety and Number of Words Recalled as a Function of Stress
0
Condition and Level of Social Anxiety
High social anxiety
High stress
State anxiety
Words recalled for each
task type
Structural
Semantic
Private self-referent
Public self-referent
20.7
.64
1.68
1.92
2.48
Low stress
17.9
.45
1.75
1.54
1.58
Low social anxiety
High stress
17.8
.42
1.29
1.92
1.79
Low stress
16.9
.54
1.88
2.04
1.50
° From Smith, Ingram, and Brehm (1983).
(1984) and Smith et αϊ. (1983) studies are consistent with the RET-derived hypothesis that heightened concern over potential negative evaluations by others is a correlate of social anxiety. While not addressing
the RET model directly, these experimental approaches may suggest
assessment technologies that are quite different from the more problematic ones described above. Such information-processing approaches do
not have the potential problems of content confound that undermine
the discriminant validity of most self-reports of irrational beliefs. Further, they do not require that subjects are aware of, and therefore can
report on, their cognitive activity. This aspect of such assessments may
be particularly useful in studies of therapy process. Kendall (1982) has
argued that self-report questionnaires (e.g., IBT) may provide underestimates of changes in cognitive processes during therapy because clients
may not initially be aware of irrational thoughts. Change scores would
be deflated because of increasing awareness of such thoughts over the
course of therapy. Thus, in addition to refinements of existing self-report approaches to the assessment of irrational beliefs, information-processing paradigms offer a rich source of possible techniques (Kihlstrom
& Nasby, 1981; Merluzzi, Rudy, & Glass, 1981).
III. IRRATIONAL BELIEFS AND THE AROUSAL OF DISTRESS
A. The Dysphoria Confound in Simple Correlational Studies
The hypothesis that irrational beliefs mediate the arousal of emotional distress is central to the RET perspective. It is not surprising,
therefore, that this assumption has inspired a large number of studies.
72
Timothy W. Smith and Kenneth D. Allred
By far the most common approach to this issue consists of correlations
between self-report measures of irrational beliefs and similar measures
of distress. At the time of the earlier review, Smith (1982) noted a large
number of such studies. Since that time additional studies have appeared, demonstrating predicted correlations of the IBT, RBI, or similar
measures with self-reported assertiveness deficits (Lohr & Bonge,
1982b), anxiety (Himle, Thyer, & Papsdorf, 1982; Rohsenow & Smith,
1982; Zwemer & Deffenbacher, 1984), low self-esteem (Daly & Burton,
1983), depression (Cash, 1984; Vestrie, 1984), and anger (Zwemer &
Deffenbacher, 1984). The results of these more recent studies are consistent with previous studies of anxiety (e.g., Goldfried & Sobocinski,
1975, Experiment 1), depression (Nelson, 1977), and assertiveness
(Alden & Safran, 1978). The endorsement of irrational beliefs has also
been found to vary as a function of DSM-III diagnoses (Newmark &
Whitt, 1983)
Although they are consistent with the RET model, the results of such
studies must be viewed with caution given the issue of discriminant
validity described above. Stated simply, rather than an association between belief and distress, correlations between these sets of measures
may simply reflect the fact that they both largely assess the same third
variable—general dysphoria (Gotlib, 1984) or negative affectivity (Watson & Clark, 1984). The results of the Smith and Zurawski (1983) and
Zurawski et αϊ. (1985) studies are consistent with this alternative interpretation.
As a direct test of this alternative explanation, the Zurawski et αϊ.
(1985) results were subjected to further analysis. Previous studies have
reported significant correlations between IBT scores (total and subscales) and the Beck (1967) Depression Inventory (Cash, 1984; Nelson,
1977) and the Novaco (1975) Anger Inventory (Zwemer & Deffenbacher,
1984). As indicated by the zero-order correlations in Table IV, the Zurawski et αϊ. results replicate this earlier work. Watson and Clark (1984)
have argued effectively that the Taylor (1953) Manifest Anxiety Scale is
a good measure of negative affectivity or neuroticism. Therefore, the
correlations between irrational beliefs, anger, and depression were recalculated, controlling for neuroticism scores via partial correlation. As
seen in Table IV, for both depression and anger, the otherwise highly
significant correlation with the IBT total score is eliminated. In the case
of depression, five of nine significant individual belief correlations are
eliminated; for anger, six of seven are eliminated. When combined with
previous data concerning the lack of discriminant validity of the irrational belief measures, this pattern suggests that studies reporting simple
correlations between beliefs and distress provide questionable support
for the RET model. As suggested earlier, a plausible alternative explana-
73
Rationality Revisited
TABLE IV
0
Correlations of IBT Scales with Depression and Anger, with and without Controlling
b
for Neuroticism
BDI
IBT scales
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Demand for approval
High self-expectations
Blame proneness
Frustration reactivity
Emotional irresponsibility
Anxious overconcern
Problem avoidance
Dependency
Helplessness
Perfectionism
Total
AI
Zero-order
Partial
Zero-order
Partial
31**
-14
06
42***
15
09
20*
14
— 30**
33**
50***
14
20*
25*
29**
32**
-09
27**
-10
38***
14
34**
01
-07
15
01
13
04
06
-02
13
49***
52***
27**
60***
31**
-28**
61***
-15
5g***
00
18
° η = 73; decimals deleted.
b
IBT, Irrational Beliefs Test; BDI, Beck Depression Inventory; AI, Anger Inventory.
* ρ < .05.
**p<.01.
*** ρ < .001.
tion for such correlations is that they reflect, to a large extent, shared
variance with dysphoria or neuroticism.
B. Manipulation of Rational versus Irrational Thought Content
A second methodological approach to testing the hypothesis that irrational beliefs produce distress has entailed experimental manipulation
of "rational" versus "irrational" thought content. Subjects are asked to
entertain such thoughts while working on a task, and their emotional
responses and task performances are assessed. A variety of studies has
provided supportive findings; irrational self-verbalizations were found
to produce increased emotional arousal (Rosin & Nelson, 1983; Russell &
Brandsma, 1974: Schuele & Wiesenfeld, 1983) and reduced task performance (Schill, Monroe, Evans, & Rumanaiah, 1978). A more recent
study of this type indicated that irrational self-statements concerning
potentially stressful situations produced more autonomic arousal than
did rational self-statements. While this finding is consistent with the
RET model, a description of the situation produced greater arousal than
did irrational statements about the situation (Masters & Gershman,
1983). The authors concluded that this pattern was explained more
74
Timothy W. Smith and Kenneth D. Allred
parsimoniously by a conditioning approach than by the cognitive mediational RET model.
In addition to somewhat mized support for the RET approach, these
studies present a conceptual problem. They reflect the widely varying
definitions of Β in the ABC model. Transitory self-statements may be
related to the more general, enduring cognitive structures implied by
Ellis's (1962) description of irrational beliefs, but they are clearly not
describing the same cognitive phenomenon. Several authors have suggested that negative self-statements may reflect the activation of irrational beliefs by situational factors (Bernard, 1981; Kendall & Hollon, 1981).
Empirical research further indicates that scores on the IBT may be
correlated with negative self-statements (Harrell, Chambless, & Calhoun, 1981), however, sometimes they are not (Davison, Feldman, &
Osborn, 1984). Nonetheless, while the results of studies of self-statements are consistent with the RET model, there is a large conceptual
difference between the transient phenomena of self-statements and the
stable, enduring cognitive structure implied by Ellis's description of
irrational beliefs. Thus, the support provided by such studies is indirect
at best.
C. Studies of Laboratory Stressors
A third methodological approach to this issue represents a compromise between simple correlational studies and experimental manipulations of thought content. Some of the problems of simple correlations are
avoided, but beliefs, rather than transitory self-statements, are included
as an independent variable. These studies categorize subjects as high or
low in their endorsement of irrational beliefs, as measured by one of the
available inventories. Various potentially stressful experimental stimuli are presented, and measures of the degree of distress are recorded.
Thus, all three elements of the ABC model are included. Because the
model posits that beliefs mediate the relationship between stressors and
distress, the high irrational belief group should demonstrate greater
emotional upset than the low irrational group. Such studies are essentially correlational because beliefs are not manipulated. They do, however, provide a fairly comprehensive test of the model.
Unfortunately, the few studies using this approach have produced
mixed results. In an often cited example, Goldfried and Sobocinski
(1975, Experiment 2) compared the emotional response of individuals
who were high or low on Ellis's belief concerning the necessity of approval from others (assessed by the IBT) while they imagined being
rejected socially. As predicted by the theory, the high irrational belief
group reported significantly more anxiety and hostility during the imag-
Rationality Revisited
75
ery task. Although these results were promising, three attempts to replicate the findings have failed to produce the expected differences between groups. Craighead, Kimball, and Rehak (1979) attempted to
duplicate the Goldfried and Sobocinski procedure precisely but could
not reproduce the findings. They did find, however, that the high irrational belief group reported more negative self-referent statements during the task than did the low irrationality group. This result provides at
least some support for the RET model.
In addition to inconsistent results, these studies suffer from several
other limitations. First, the stressors are quite artificial, causing concerns about the generalization of the results to actual emotion-arousing
events. Second, the irrational beliefs employed are specific to the stressor. These studies did not examine the influence of general irrationality
or beliefs that are not relevant to the stressor on the arousal of distress.
Previous studies of trait anxiety suggest that measures of situation-specific trait anxiety (e.g., test anxiety) are more predictive of the arousal of
state anxiety than are measures of general trait anxiety. Thus, situation-specific irrational beliefs should predict the arousal of distress better than general irrationality (Kendall, 1978; Mellstrom, Zuckerman, &
Cicala, 1978). Further, it seems logical that situation-relevant rather
than -irrelevant beliefs should also be more predictive. The RET model
seems to imply that for an irrational appraisal tendency to arouse affect,
it must concern the situation in question. Finally, previous studies did
not examine the comparative utility (Mischel, 1968) of measures of
beliefs and other individual differences in predicting distress. That is, no
previous studies determined whether measures such as the IBT predict
distress better than do measures of more parsimonious a n d / o r more
established constructs such as trait anxiety. If the measures of more
parsimonious constructs proved to be better predictors, then the utility
of belief measures would be in doubt, as would the necessity of postulating the existence of the mediating cognitive construct in accounts of the
arousal of distress.
To address these concerns, Smith, Houston, and Zurawski (1984b)
examined subjects' self-reported affect, negative self-statements, and
physiological arousal during high and low social-evaluative threat.
Subjects' levels of state anxiety and physiological arousal (i.e., finger
pulse volume, pulse rate) were recorded during a baseline period and
during their participation in one of two experimental conditions. In the
high threat condition, subjects' responses to an interview were videotaped, ostensibly to be evaluated later to assess the level of verbal intelligence evident in their answers. In the low threat condition, subjects
responded to the same questions, but no video camera was present and
any evaluative aspects of the experiment were explicitly deempha-
76
Timothy W. Smith and Kenneth D. Allred
sized. After the interview, all subjects completed thought-listing (Cacioppo & Petty, 1981; Kendall & Hollon, 1981) and self-statement inventory (Kendall & Hollon, 1981) assessments of their cognitive activity
during the questions. These assessments were used to measure three
types of negative cognitive activity: preoccupation with stressful aspects
of the situation, self-denigration, and denigration of the situation. Prior
to the experimental session, subjects had completed the IBT and the
Fear of Negative Evaluation Scale (FNE; Watson & Friend, 1969). Belief
in the necessity of high achievement and belief in the necessity of
approval by others from the IBT were considered relevant to the evaluative threat presented by the stressor; the belief in determination of one's
future by the past was considered the irrelevant belief. The total IBT
score served as the index of general irrationality, and the FNE score was
the measure of the less inferential, more parsimonious individual difference variable.
Consistent with RET predictions, belief in the necessity of approval
was associated with cognitive preoccupation. Belief in the necessity of
high achievement was associated with cognitive preoccupation and
self-denigration. Neither belief, however, was related to self-reported
anxiety or physiological arousal during the interview. The irrelevant
irrational belief and general irrationality were not related to any measure of distress. These results extend previous findings by indicating
that specific, relevant irrational beliefs predicted cognitive concomitants of distress during exposure to a potentially threatening event better than did an irrelevant, specific belief or general irrationality. Thus,
consistent with previous findings concerning anxiety (Kendall, 1978;
Mellstrom et αϊ., 1978), irrationality concerning the specific class of
situations, rather than irrationality per se, was related to distress.
Examination of the FNE findings cast these results in a different light,
however. The FNE predicted the level of state anxiety during the interview, as well as the degree of cognitive preoccupation and self-denigration. Further, the FNE predicted levels of negative cognitive activity
above and beyond that accounted for by the specific, relevant beliefs. In
contrast, the irrational beliefs did not account for variance in negative
cognition beyond that accounted for by FNE. Thus, although the results
provided some support for the RET model, they also indicated that the
IBT has limited predictive utility. A more parsimonious, less inferential
construct provided a better account of the arousal of distress than did
the most popular operational definition of irrational beliefs. This finding
calls into question the current status of this type of empirical support for
RET, and perhaps even questions the need to postulate the existence of
irrational beliefs.
Rationality Revisited
77
D. Irrationality, Life Events, and Distress
The social-evaluative threat that was used by Smith et al. (1984b)
provided a reasonably compelling operational definition of the A in the
ABC model. It was, however, a short-term laboratory analogue. As such,
it provided a controlled experimental test, but may or may not generalize to the kind of actual events that serve as sources of emotional distress. As a nonlaboratory complement to the Smith et αϊ. (1984b) study,
Smith, Boaz, and Denney (1984a) examined the role of irrational beliefs
in moderating the relationship between stressful life events and both
emotional and physical distress. If, as predicted by the RET perspective,
irrational beliefs mediate the arousal of distress following stressful
events, individuals high in irrationality should be more vulnerable to
the negative emotional and physical effects of stressful life changes than
their low irrationality counterparts. This mediational pattern would be
reflected in the statistical moderation of the relationship of negative life
events and reported distress. That is, the RET vulnerability hypothesis
would predict that the correlation of stressful events with subsequent
emotional and physical symptoms would be greater for high versus low
irrationality groups.
To test this hypothesis, Smith et al. (1984a) asked 136 undergraduates
(53 males, 83 females) to complete a measure of recent life events (Sarason, Johnson, & Siegel, 1978) and the RBI. Approximately 8 weeks later,
subjects returned to complete a measure of psychological distress (Lanyon, 1970) and a measure of health problems (Marx, Garrity, & Bowers,
1975). Based on a median split, subjects were categorized as high or low
in irrationality. Multiple regression analyses were performed to examine the relationship of irrationality, life events, and their interaction
with subsequent physical and emotional distress.
Consistent with previous research, negative life events were significantly correlated with subsequent emotional distress and physical
symptoms. Consistent with the RET model, irrationality was associated
with higher subsequent emotional and physical distress. That is, the
irrationality main effect was significant for both forms of distress. As
described above, the ABC model is best tested by the interaction of
stressful events and irrationality. Contrary to prediction, this interaction was not significant in the case of emotional distress. That is, although they reported more emotional distress in general, the high irrationality group was not more emotionally vulnerable to the effects of
stressful events than was the low irrationality group. This pattern is
depicted in Fig. 1 A. The predicted interaction was obtained for physical
symptoms, however. Thus, as predicted by the vulnerability notion, the
association between life events and physical symptoms was signifi-
Timothy W. Smith and Kenneth D. Allred
78
Α
Β
τ—ι—ι—ι—ι—ι—
5
D
«
20
25
30
NEGATIVE LIFE EVENTS
1
—ι—ι—ι—ι—ι—Γ
5
ID
«
20
25
30
NEGATIVE LIFE EVENTS
Fig. 1. Relationship of negative life events to emotional (A) and physical symptoms (B)
as a function of irrationality. Adapted from Smith, Boaz, and Denney (1984a).
cantly greater for the high versus low irrationality groups. This pattern
is depicted in Fig. I B .
Failure to find the predicted belief by stress interaction for emotional
distress adds to the general concern about the accuracy of the RET
model outlined above. The fact that the analogous interaction was
found for physical symtpoms is curious. It could be taken to mean that
the RET perspective is a more accurate model of the development of
physical than emotional difficulties. This explanation seems unlikely
given that the chronic arousal believed to link stressful events and the
development of illness would probably be associated with subjective
distress, especially for highly irrational individuals. A more likely explanation involves the contamination of irrational belief measures with
neuroticism. Although the RBI shows somewhat better discriminant
validity relative to neuroticism than does the IBT, its discriminant validity is not compelling (Smith & Zurawski, 1983; Zurawski et al.. 1985).
Because its association with neuroticism is high, the significant interaction between the RBI and stress for illness reports may actually reflect
an interaction between neuroticism or dysphoria and life events. Dysphoric or neurotic individuals may be more likely to actually develop
illness (Cantor, 1972; Cantor, Cluff, & Imboden, 1972) or may simply
report more physical symptoms (Cohen, 1979; Costa & McCrae, 1985)
following significant stressors. While the interaction for physical symptoms is interesting and deserving of further research, the overall results
of the Smith et al. (1984a) study do not provide unequivocal support for
the ABC model of emotional distress.
Rationality Revisited
79
IV. IRRATIONAL BELIEFS AND THE PROCESS OF
THERAPEUTIC CHANGE
Previous reviews of the RET treatment outcome, literature have concluded that the therapy is generally effective (Smith, 1982; SuttonSimon, DiGuiseppe, & Miller, 1978). It produces effects beyond that
attributable to nonspecific factors in both mildly disturbed (e.g., Kanter
& Goldfried, 1979) and more serious clinical populations (e.g., Lipsky,
Kassinove, & Miller, 1980). Recent efforts have applied RET and related
techniques to new problems (e.g., Type A behavior; Thurman, 1985),
and attempted to identify subgroups that would respond most favorably
to such cognitively based interventions (Gross & Fremouw, 1982).
Central to the RET model of therapeutic change is the modification of
irrational thinking. Improvement follows the identification and elimination of irrational beliefs. Thus, changes in distress require changes in
beliefs. Given the importance of this hypothesis, it is surprising that few
of the RET outcome studies have included measures of this hypothesized mediating variable. Those that did have generally demonstrated
that RET produces lower scores on measures of irrational beliefs as well
as improvements on outcome measures (Kanter & Goldfried, 1979;
Lipsky et αϊ., 1980; Trexler & Karst, 1972; Alden, Safran, & Weideman,
1978; Craighead, 1979).
While parallel changes in beliefs and distress provide indirect evidence for the RET explanation of change, these studies did not take the
next obvious step of examining the correlation of changes in beliefs with
changes in distress. The RET approach predicts that such correlations
should be highly significant. Although such analyses would not test the
causal hypothesis explicit in the theory, a minimum degree of support
would be provided by significant correlations between changes in the
mediating mechanism and changes in outcome variables.
To examine this issue, Smith (1983) reanalyzed the data reported by
Lipsky et αϊ. (1980). Lipsky et αϊ. randomly assigned 50 adults accepted
for outpatient treatment at a community mental health center to one of
five conditions: standard RET, RET plus rational role reversal, RET plus
rational-emotive imagery, alternative treatment (supportive therapy
plus relaxation training), or a waiting list control. Before and after treatment (or the waiting period), subjects completed self-report measures of
distress and the Idea Inventory, a self-report measure of irrational beliefs that is scored such that higher values reflect Jess irrational thinking.
Thus, higher scores on this measure should be correlated with lower
scores on measures of distress. The results of the Lipsky et αϊ. (1980)
study indicate that the three RET treatments produced significantly less
distress and irrationality relative to the two control groups.
Timothy W. Smith and Kenneth D. Allred
80
The results of Smith's (1983) reanalysis are presented in Table V.
Consistent with many other studies reporting relationships between
irrationality and distress, the correlations in the first row of the table
indicate that before-treatment endorsement of irrational beliefs was
associated with greater depression, anxiety, and neuroticism. The correlations in Row 2 reflect the expected association of change scores.
Reductions in distress (adjusted for initial level and group membership)
were significantly correlated with increases in rationality (also adjusting for initial level and group) in each of the four cases. Examination of
the correlations in Row 3 reveals that these predicted associations were
found for three of the four outcome measures when the RET groups
were examined separately. However, all four correlations were significant when the control groups are considered separately. Thus, the predicted association between increases in rationality and decreases in
distress was at least as strong in conditions where beliefs were not
expected to change as they were in conditions intended to influence
beliefs.
The overall change correlations (Row 2) and those within the RET
groups (Row 3) could be interpreted as consistent with the model. The
findings for the control condition are somewhat more troublesome.
They could reflect an association between beliefs and distress as patients improved or deteriorated in the absence of active treatment. However, according to the RET perspective, irrational beliefs are highly
resistant to change in the absence of active intervention (Ellis, 1962).
These correlations could also be viewed as consistent with the problem
of the low discriminant validity of measures of irrationality. Instead of
reflecting covariation of beliefs and distress, an alternative interpretation of the results is that they reflect covariations among measures of
general dysphoria in both treatment and control conditions. Thus, as
TABLE V
0
6
Correlations of Beliefs with Outcome Measures
MAACL-A
Within pretreatment
Adjusted change
RET groups
Control groups
0
-19
— 4^**
-19
-63**
Decimals have been deleted.
From Smith (1983).
* ρ < .05.
** ρ < .01.
*** ρ < .001.
b
MAACL-D
-30*
— 48**
-62**
STAI-T
EPI-N
-48***
-53***
-56***
— 57***
-68***
-63***
7 7 * *
-64**
Rationality Revisited
81
with other basic hypotheses in RET, examination of the therapeutic
process requires additional development of cognitive assessment techniques.
V. CONCLUSIONS: CONTINUED COMPLAINTS AND
LINGERING LIMITATIONS
In an earlier review, Smith (1982) outlined several problems with the
body of theory and research associated with RET. The intervening time
has brought several of these concerns into sharper focus but eliminated
very few. At that time the theoretical model had grown into a more
general and expansive but less specific and testable form (Ewart & Thoreson, 1977; Mahoney, 1977a; Meichenbaum, 1977). An example of this
problem is the meaning given to the Β in the ABC model. It variously
refers to transitory covert verbalizations, stable philosophical assumptions, and illogical processing of information. Refinements in the theory
are obviously required if empirical evidence is to be acquired in a useful, systematic fashion. Such refinements have been suggested (e.g.,
Bernard, 1981), but they have yet to be incorporated into the mainstream of RET theory and research. Thus, the lack of precision in definitions of key RET concepts and hypotheses regarding their interrelationships has not yet been addressed.
The gaps in empirical support for the central tenets of RET remain.
Simple correlations between measures of beliefs and measures of distress form the bulk of empirical support for the hypothesis that beliefs
mediate the arousal of distress. Such correlations could reflect the predicted association between beliefs and distress. Additional research,
however, has demonstrated that these simple correlational studies may
be seriously misleading. It is equally plausible that the obtained associations between beliefs and distress actually reflect mutual assessment of
general dysphoria (Smith & Zurawski, 1983; Zurawski et αϊ., 1985). Potentially more definitive studies of the arousal of distress in laboratory
and life stress paradigms have not been consistent with the model
(Smith et αϊ., 1984a,b). Finally, little evidence exists to test the RET view
of therapeutic process. The one study that does exist (Smith, 1983) provides at best only partial support.
At the core of these empirical problems is the issue of measurement.
Our reassessment of this literature points to the assessment of irrationality as a central concern. At present, we have no basis to conclude
whether the various empirical failures to support the model are due to
the model's inaccuracy or to the lack of valid measures of beliefs. The
evidence that does exist, however, must be viewed as mixed support at
82
Timothy W. Smith and Kenneth D. Allred
best. Many confirmatory findings are open to alternative explanations,
and several negative results have appeared.
The empirically oriented clinician is presented with a dilemma that is
familiar in our discipline. On the one hand, we have a popular therapeutic technique, generated from an intuitively appealing framework, that
has some demonstrated effectiveness. On the other, although the theory
sounds quite accessible for empirical research, its 25-year history has
produced a large body of methodologically limited tests of basic tenets
and, in recent years, several direct challenges (Craighead et αϊ., 1979;
Smith et αϊ., 1984a,b). Of course, the popularity and even effectiveness of
interventions do not provide support for the models of adjustment from
which they are derived. Given our critique of the assessment of beliefs,
one could argue that the otherwise accurate model has not been given
an appropriate test. It may also be, however, that RET provides an
effective intervention but a misleading account of maladjustment and
the process of change. The ABCD framework may be a useful metaphor
but an inaccurate theory. Chronic maladaptive emotions may occur for
a variety of reasons that have little to do with irrational beliefs. But
indeed, distressed people behave as if they believed various irrational
things. If at the hands of the RET therapist, clients are persuaded to
consider the logical evidence that they must believe such things, clients
may infer the existence of these beliefs, even if they were never held. The
client's "discovery" of irrational beliefs may actually reflect a process of
inference that parallels the RET therapist's "discovery" of beliefs hypothesized by the theory. This suggestion is consistent with Eschenroeder's (1982) observation that "verbatim transcripts of dialogues
between Ellis and his clients show that inferred beliefs are sometimes
treated as if the client had actually experienced them" (p. 388). Viewing
their behavior as produced in such a way, clients may be encouraged to
exercise conscious control over previously automatic, uncontrolled
emotional responses. This explanation is admittedly speculative. Furthermore, most, if not all, rational-emotive therapists would find it an
insufficient account of therapy process. Under close scrutiny, however,
the current empirical evidence provides only faint scientific justification for rejecting it in favor of the proponents' view.
Our present purpose, however, is not to provide alternative explanations for the effect of RET techniques. It is to review the status of empirical research in this area and to suggest avenues for future work. Conceptual refinements and valid assessment methodologies are obviously
needed, as are systematic applications of those potential developments
to studies of the arousal and modification of distress. Such efforts are
critical if the RET perspective is to continue its role in the vital cognitive
trend in psychotherapy (Mahoney, 1977b). Other cognitive approaches,
Rationality Revisited
83
such as the information-processing paradigms, are currently more accessible to rigorous clinical research (Ingram, 1986; Kihlstrom & Nasby,
1981; Merluzzi, et αϊ., 1981). The RET model is in danger of eventual
replacement by such experimental approaches, rather than integration
with them, if it does not become more empirically testable and
grounded. The RET model has much to gain if it can expand in a controlled fashion in response to such developments, including the current
debate regarding the primacy of cognition versus affect (Lazarus, 1984;
Zajonc, 1984). Similarly, the causal role of cognition in emotional distress has been criticized, and more complex cognitive-social interactional alternatives proposed (Coyne, 1982; Coyne & Gotlib, 1983). The
RET model may profit from systematic integration with these models as
well. Implicit in such developments is the promise that the RET framework will continue to contribute to a more complete understanding of
the nature and treatment of emotional distress. If the problems with
RET research that we have outlined persist for several more years,
however, this promise is almost certain to be broken.
ACKNOWLEDGMENTS
The authors would like to thank Jim Alexander, Phil Kendall, Fred Rhodewalt, and Don
Strassberg for comments on a previous draft of the manuscript.
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Changes in Depressive Beliefs: An
Analysis of Beck's Cognitive Therapy
for Depression
JOHN S. MARZILLIER
Department of Clinical Psychology
The Warneford Hospital
Oxford 0X3 7JX, England
I. Introduction
II. Beck's Cognitive Therapy for Depression
A. The Cognitive Model of Depression
B. The Development of Depression
C. Beck's Cognitive Therapy
D. The Effectiveness of Cognitive Therapy
III. Critical Appraisal of Beck's Cognitive Therapy
A. The Cognitive Model of Depression Revisited . . . .
B. Schemas Revisited
IV. Rowe's Personal Construct Therapy
A. Rowe's Model of Depression
B. Metaphysical and Rational Beliefs
C. Changing Beliefs
D. Alternative Value Systems
V. Conclusions
References
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I. INTRODUCTION
Cognitive-behavioral methods of treatment continue to flourish despite occasional doubts expressed about their effectiveness (e.g., Ledwidge, 1978; Miller & Berman, 1983) and theoretical qualms concerning
analyses of cognition (e.g., Zajonc, 1980). The marriage of behavioral
procedures and cognitive processes has proved a durable one, no more
so than in the treatment of emotional disorders such as anxiety and
depression. One of the major contenders in this arena is the system of
cognitive therapy developed and researched by Beck and his colleagues
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AND THERAPY, VOLUME 5
Copyright © 1986 by Academic Press, Inc.
All rights of reproduction in any form reserved.
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John S. Marzillier
(Beck, 1976; Beck, Rush, Shaw, & Emery, 1979). Beck's cognitive therapy
(a cognitive-behavioral treatment) is a highly structured and systematic approach to the treatment of depression in particular and of emotional disorders in general. It offers the promise of a viable psychological
alternative to existing treatments of depression, antidepressant medication in particular. There is little doubt that many psychologists and
psychiatrists are attracted by the promise of this intervention. Research
over the next few years will hopefully help to unravel some of the
complex questions raised by cognitive therapy. How effective is cognitive therapy as a method of treatment for depression? What role is
played by the various cognitive, behavioral, and affective components
to the treatment? How well does the cognitive model of depression
account for the phenomenon of depression?
In this article I have considered in the main the theoretical status of
cognitive therapy with particular reference to two key issues: (1) the
status of the cognitive model of depression and (2) the focus on the
changing of dysfunctional beliefs. Both issues are central to cognitive
therapy. In the cognitive model of depression, distorted thinking processes are regarded as the prime cause of the symptoms of depression.
Hence, the aim of the therapy is to identify and modify these distortions.
Although distorted thinking takes several forms (e.g., negative automatic thoughts, overgeneralization, arbitrary inference), Beck et al.
(1979) assert that underlying assumptions, beliefs, or schemata are the
key to the production and maintenance of depression. Successful therapy should help patients identify these beliefs and change them. Both
these theoretical claims are critically reviewed. In order not to misrepresent Beck's ideas and to be as accurate as possible about their status, I
have quoted liberally from Beck's major writings. In the latter part of the
article Rowe's personal construct therapy for depression is introduced
(Rowe, 1978, 1983). Rowe's ideas about the nature of depressive beliefs
and the way that these may be changed are directly relevant to Beck's
central claims.
II. BECK'S COGNITIVE THERAPY FOR DEPRESSION
Beck has written extensively on the so-called paradoxes of depression, that is, the tendency in depressed people to act against their own
welfare and their natural instincts. Interestingly, Beck's cognitive therapy also provokes a paradox: This highly psychological and pragmatic
method of treatment was in fact developed by a psychoanalytically
trained psychiatrist with a strong background in conventional, diagnostic medicine. Just as the "paradoxes" of depression are revealed after
Changes in Depressive Beliefs
91
careful analysis not to be paradoxical at all, so cognitive therapy reflects
something of the background of its originator that might at first not be
obvious.
It was Beck's psychoanalytical training that led him to listen carefully
to his patients' thoughts and feelings. He describes how he first became
aware of the importance of negative thoughts.
A patient in the course of free association had been criticizing me angrily. After a
pause, I asked him what he was feeling. He responded, "I feel very guilty." At the time,
I was satisfied that I understood the sequence of psychological events. According to
the conventional psychoanalytic model, there was a simple cause-and-effect relation
between his hostility and guilt; that is, his hostility led directly to guilty feeling. There
was no need, according to the theoretical scheme, to interpose any other links in the
chain.
But then the patient volunteered the information that while he had been expressing anger-laden criticisms of me, he had also had continual thoughts of a self-critical
nature. He described two streams of thought occurring at about the same time: one
stream having to do with his hostility and criticisms, which he had expressed in free
association, and another that he had not expressed. He then reported the other stream
of thoughts: "I said the wrong thing . . . I shouldn't have said that . . . I'm wrong to
criticize him . . . I'm bad . . . He won't like me . . . I'm bad . . . I have no excuse for being so mean."
This case presented me with my first clear-cut example of a train of thought running parallel to the reported thought content. I realized that there was a series of
thoughts that linked the patient's expression of anger to guilty feelings. Not only was
the intermediate ideation identifiable, but it directly accounted for the guilty feeling:
The patient felt guilty because he had been criticizing himself for his expressions of
anger to me. (Beck, 1976, pp. 30-31)
In the strong psychoanalytical tradition extending back to Freud,
Beck shows a willingness to listen carefully to the messages delivered by
his patients. One of the main attractions of cognitive therapy is how well
it is steeped in actual case material in a way that makes it "alive" to
potential therapists and highly plausible to many patients. The techniques and methods of cognitive therapy have by and large been developed out of clinical case material in a way that parallels the early development of psychoanalysis. A major difference has been, however, the
degree to which cognitive therapy, unlike much of psychoanalysis, has
been subjected to systematic scientific study.
Beck has always striven to put his therapeutic ideas and practices on a
solid scientific footing. His first major contribution to the analysis of
depression (Beck, 1967) is a model of scientific theorizing and experiment, so much so that the reviewer for the American Journal of Psychiatry described the book as "interestingly written, highly informative,
well documented, and of high scientific quality." In this book Beck
describes a series of systematic experiments on depressed patients in
which, by rigorous assessment and careful comparisons, he sought to
John S. Marzillier
92
isolate and describe the key features of depression. The diagnostic
training is also evident in the way Beck draws an analogy between the
causes of depression and those of respiratory disorders.
Thus, in taking a "cross section" of the symptomatology of depression, we have
arrived at the position that we should look for the primary psychopathology in the
peculiar way the individual views himself, his experiences, and his future (the "cognitive triad") and his idiosyncratic way of processing information (arbitrary inference, selective recall, overgeneralization, etc.). Our clinical experience and experimental work suggest that the parallel to a lung lesion may be useful. The most florid
manifestations of depression may distract the clinician (as well as the patient) from
even noting the locus of significant pathology. Just as in the case of a "silent tumor" of
the lung, the most dramatic symptoms may be physical pain, cough, and weakness, so
in depression the overriding symptoms may be psychic pain, agitation, and loss of
energy. If the diagnostician does not search for other pathology, he may miss the
primary phenomenon in the chain of events, namely the thinking disorder. (Beck et
αϊ., 1979, p. 19)
The "primary phenomenon in the chain of events" is, according to
Beck, the patient's thinking disorder. And Beck applies considerable
diagnostic skill in elucidating and assessing the nature of that disorder.
In fact, this aspect of cognitive therapy is quite possibly its most significant contribution. Beck has shown clinicians how to pin down and
describe in a systematic way the elusive, intricate, and complex cognitions of depressed people. He opened up the way for diagnosticians to
incorporate thinking processes into their formulations of clinical depression and for therapists to focus on these processes in an ordered and
precise manner. T h e assessment and modification of negative automatic
thoughts are prime examples of this approach.
Cognitive therapy is, therefore, a logical product of both the psychoanalytic and the diagnostic tradition. Of course, there is much more to
cognitive therapy than those traditions. And it is clear that Beck regards
cognitive therapy as defining a separate and quite distinct tradition, a
radical alternative to existing therapeutic approaches (Beck, 1976).
A. The Cognitive Model of Depression
The cognitive model postulates three specific concepts to explain the psychological
substrate of depression: (1) the cognitive triad, (2) schémas, and (3) cognitive errors
(faulty information processing). (Beck et αϊ., 1979, p. 10)
1. The Cognitive Triad
The cognitive triad consists of three major cognitive patterns: negative view of self, negative view of the world, and negative view of the
future. Beck considers these patterns of thought distorted and idiosyncratic, and responsible for the observed symptoms of depression (see
Fig. 1).
93
Changes in Depressive Beliefs
Depressed mood
Negative view of world
Paralysis of will
Negative view of self
Avoidance wishes
Suicidal wishes
Negative view of future
Increased dependency
Fig. 1. The effect of cognitive patterns on depressive symptomatology. [Reprinted with
permission from Beck (1967, p. 256).]
The cognitive triad is a key feature of the cognitive model of depression since it is from these negative perceptions that the depressed person's problems arise. Negative thinking processes underlie the person's
emotional responses, i.e., his depressed mood. Thus "if a patient incorrectly thinks he is being rejected, he will react with the same negative
affect . . . that occurs with actual rejection" (Beck et αϊ., 1979, p. 11).
The cognitive triad is important for two reasons. First, it is an expression of the primacy of cognitive distortions in the symptomatology of
depression. They are the first cause like the "silent tumor" in underly1
ing respiratory problems. If depression is to be properly understood
(diagnosed), then the clinician must unlock these negative thought processes. Depression cannot adequately be understood without reference
to them.
Second, these thought processes are seen as distorted and idiosyncratic. Reality is in fact very different from the negative perceptions of
the depressed person; his thinking is discordant with reality. This logically leads to a therapeutic enterprise aimed at correcting these distortions and enabling the person to see that reality is in fact very different.
Both the primacy of negative thinking and its discordance with reality
are major premises in Beck's cognitive model of depression.
2. Schemas
Beck postulated the existence of "schémas" or "cognitive structures"
to explain how depressed people organize their thinking processes and
why they remain consistent over time.
a
The primacy of cognitive distortion is not the same as asserting ultimate causation as
Beck is keen to point out (see Beck et ed., 1979, pp. 17-20). Rejecting the notion of a single
cause, Beck (1983) sees depression as "the final common pathway of many converging
variables" with cognitive distortion as the psychological filter through which depression
manifests itself in actual experience.
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John S. Marzillier
Any situation is composed of a plethora of stimuli. An individual selectively attends
to specific stimuli, combines them in a pattern, and conceptualizes the situation.
Although different persons may conceptualize the same situation in different ways, a
particular person tends to be consistent in his responses to similar types of events.
Relatively stable cognitive patterns form the basis for the regularity of interpretations
of a particular set of situations. The term "schema" designates these stable cognitive
patterns. (Beck et αϊ., 1979, p. 12)
In depressed people, powerful dysfunctional schémas are activated
and these determine the depressed person's negativity and selectivity of
response. In severe depression, the person's thinking can be almost
entirely dominated by such schémas to the extent that he or she will be
virtually unresponsive to external events and entirely preoccupied
with depressive thoughts.
Schemas play an important role in Beck's model of depression. First,
they provide a model of cognitive organization. Thus "cognitive structures are relatively enduring characteristics of a person's cognitive organization. T h e y are organized representations of prior experience; different aspects of experience are organized through different schemata"
(Kovacs & Beck, 1978, p. 526). Second, they apparently explain the predominance of negative thinking, how it arises, how it is activated, and
how it is maintained. I write "apparently" since, as Teasdale (1983) has
noted, the mechanisms through which schémas are activated are not
clearly specified and their exact structure and function not wholly
clear. Third, the major goal of cognitive therapy is "to identify, reality
test, and correct distorted conceptualizations and the dysfunctional beliefs (schémas) underlying these cognitions" (Beck et αϊ., 1979, p. 4). To
achieve lasting change in depressive symptomatology, the person's
schémas must be changed, not merely their symptoms alleviated.
3. Cognitive Errors
Beck identifies systematic errors in the cognitive processing of depressed people that serve to maintain their negative thinking and depressive beliefs. S i x common distortions or errors are noted.
1. Arbitrary inference (a response set) refers to the process of drawing a specific
conclusion in the absence of evidence to support the conclusion or when the evidence
is contrary to the conclusion.
2. Selective abstraction (a stimulus set) consists of focusing on a detail taken out of
context, ignoring other more salient features of the situation and conceptualizing the
whole experience on the basis of this fragment.
3. Overgeneralization (a response set) refers to the pattern of drawing a general rule
or conclusion on the basis of one or more isolated incidents and applying the concept
across the board to related and unrelated situations.
4. Magnification and minimization (a response set) are reflected in errors in evaluating the significance or magnitude of an event that are so gross as to constitute a
distortion.
Changes in Depressive Beliefs
95
5. Personalization (a response set) refers to the patient's proclivity to relate external
events to himself when there is no basis for making such a connection.
6. Absolutistic, dichotomous thinking (a response set) is manifested in the tendency
to place all experiences in one of two opposite categories; for example, flawless or
defective, immaculate or filthy, saint or sinner. In describing himself, the patient
selects the extreme negative categorization. (Beck et αϊ., 1979, p. 14)
These cognitive errors are products of depressive schémas and serve to
distort reality to "fit in" with the schémas. Hence, they provide important clues to the person's depressive thinking and in therapy a means of
counteracting such thinking.
B. The Development of Depression
Central to Beck's theory of the development of depression is his concept of schema. A depressive episode occurs as a result of the reactivation of depressive schémas usually, although not always, under circumstances similar to those that provoked a depressive response in the first
place, viz.,
During their development and maturation people develop a large number of schemata that organize different aspects of experience. The schemata ostensibly undergo
modification as a result of living, learning, and experiencing. The formal characteristics of most depressogenic schemata, including the psychologically simplistic and
"childish" content of the premises, the rigid directives, and their apparent lack of
differentiation, all combine to create the impression that we are dealing with relatively stable, developmentally early constructions. In other words, it appears that
most of these schemata contain erroneous conclusions which stem from the patient's
earlier years and which have remained fairly constant through years of living. The
functional utility of these schemata apparently has not been systematically tested
against the changing reality of the maturing person. Their content and their process
characterstics have not been modified to parallel the increasing flexibility and complexity of other (nondepressogenic) schemata. (Kovacs & Beck, 1978, p. 529)
In other words, people become depressed because of (a) specific vulnerability, i.e., their personal history has resulted in the formation of depressive schémas that will be activated by (b) specific stresses, i.e., the occurrence of stressful events that often resemble earlier depression-making
experiences. Loss, deprivation, and death are common themes. Thus "a
schema that originally developed as a consequence of the death of a
close relative during the patient's childhood may be readily reactivated
by any death the patient confronts during adulthood. The schema may
be reactivated by conditions that the adult interprets as constituting
irrevocable loss such as the disruption of an interpersonal relationship"
(Kovacs & Beck, 1978, pp. 5 2 9 - 5 3 0 ) .
Other factors, such as nonspecific stresses, "psychological strain," or
biochemical abnormalities, can also contribute to the development of
depression. But the major process, according to Beck, is the formation
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John S. Marzillier
and reactivation of depressive schémas acquired and developed during
childhood.
C. Beck's Cognitive Therapy
Beck (1983) described cognitive therapy as "an active, directive, time
limited, structured approach . . . based on an underlying theoretical
rationale that an individual's affect and behavior are largely determined
by the way in which he construes the world." The aims of treatment are
to (1) identify, reality test, and correct distorted conceptualizations and
the dysfunctional beliefs (schémas) underlying these cognitions; (2) help
the patient learn to master problems and situations previously thought
insuperable; and (3) allow the patient to experience symptomatic improvement such as mood change. To achieve lasting change, as opposed
to a temporary shift in mood, it is believed necessary to change the
underlying beliefs or schémas and indeed a major part of cognitive
therapy is directed at belief change.
Cognitive therapy consists of a general strategy and a number of tactical procedures or therapeutic techniques. The strategy is known as
collaborative empiricism:
An active collaboration is sought between
therapist and patient to tackle the patient's depression in a structured,
goal-directed, and systematic manner, using monitoring sheets, activity
schedules, carefully structured therapy sessions with agreed agenda,
homework assignments, and a variety of specific techniques. In this
emphasis on active collaboration and problem solving, cognitive therapy closely resembles many of the existing behavioral or cognitivebehavioral treatments. In addition to active collaboration, the major
thrust of the treatment is on empirical investigations of distorted thinking and maladaptive beliefs.
The overall strategy of cognitive therapy may be differentiated from the other schools
of therapy by its emphasis on the empirical investigation of the patient's automatic
thoughts, inferences, conclusions, and assumptions. We formulate the patient's dysfunctional ideas and beliefs about himself, his experiences, and his future into hypotheses and then attempt to test the validity of these hypotheses in a systematic way.
Almost every experience, thus, may provide the opportunity for an experiment relevant to the patient's negative views or beliefs. If the patient believes, for example, that
everybody he meets turns away from him in disgust, we might help him to set up a
system for judging other people's reactions and then motivate him to make objective
assessments of the facial expressions and bodily movements of other people. If the
patient believes he is incapable of carrying out simple hygienic procedures, we might
jointly devise a checklist or graph which he can use to record the degree of success in
carrying out these activities. (Beck et αϊ., 1979, p. 7)
The essential aspect of the strategy as a whole is to teach patients to
recognize and change their distorted ways of thinking, by a highly
Changes in Depressive Beliefs
97
structured program of activity in which testing the logic and reality of
their thinking processes is the central component.
Cognitive therapy embraces a variety of tactical procedures or specific treatment techniques, which are described in detail and richly
illustrated in Beck et αϊ. (1979). Some of these procedures are listed
below:
1. Presentation of the rationale of cognitive therapy. The relationship of cognition to
emotion is modeled in the initial interviews, elicited from patients, and illustrated in
a hand-out entitled "Coping with Depression" (Beck & Greenberg, 1974).
2. Identification and monitoring of negative automatic thoughts (NATs). Patients
are taught to recognize NATs and to monitor them systematically using a special
record sheet.
3. Monitoring and developing activities. Using an activity schedule, patients monitor and record all their daily activities, rating these for pleasure (P) and mastery (M).
Increased and different activities may be targeted, recorded, and rated.
4. Counteracting negative automatic thoughts. Patients are taught not to accept
NATs at face value, but to counteract them by logical argument, hypothesis testing,
generating alternative hypotheses, and reality testing.
5. Monitoring and correcting cognitive errors. When errors such as arbitrary inference or overgeneralization are made, patients are encouraged to recognize and correct them.
6. Identifying and modifying dysfunctional assumptions. In the later stages of therapy underlying assumptions are elicited by systematic questioning, examining recurrent themes, drawing inferences from NATs and cognitive errors, picking up clues
from global attributions, and, occasionally, historical accounts of the patient's early
life. The assumptions are modified directly by counterarguments, hypothesis testing,
listing pros and cons, and behavioral change procedures.
These are by no means the only procedures used in Beck's cognitive
therapy. The therapy is a complex package of various procedures and is
individually tailored to the needs and problems of each patient.
D. The Effectiveness of Cognitive Therapy
There have been an increasing number of studies evaluating the effectiveness of Beck's cognitive therapy for depressed patients and comparing the therapy to alternative therapies, such as antidepressant medication and psychodynamic psychotherapy (e.g., Blackburn, Bishop,
Glen, Whalley, & Christie, 1981; Rush, Beck, Kovacs, & Hollon, 1977;
Shaw, 1977; Teasdale, Fennell, Hibbert & Amies, 1984). The preliminary
results are promising and suggest that cognitive therapy can more than
hold its own as a method of treatment for depressed people, and that it
may hold some advantages over alternatives such as antidepressant
medication.
Rush et al. (1977), for example, found cognitive therapy to result in
greater improvement on depressive symptoms than drug treatment and
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John S. Marzillier
to produce significantly fewer drop-outs. Blackburn et al. (1981) reported a significantly better response to cognitive therapy from depressed patients attending general practice than to drug treatment, although the possibility that this was due to poor compliance in the
drug-treated patients could not be ruled out. They did not, however,
find the same effect in psychiatric outpatients, in whom a combination
of cognitive therapy and drug treatment proved to be more effective in
relieving depression symptoms than either treatment alone.
Teasdale et al. (1984) reported that cognitive therapy produced a clinically and statistically significant improved rate of recovery for depressed patients referred from general practice compared to "treatment
as usual." Patients receiving cognitive therapy showed significantly
greater improvement in depression at the end of treatment than the
comparison group, but the comparison group "caught up" by the end of
the 3-month follow-up period. Teasdale et α J. (1984) commented that
many of the patients treated by cognitive therapy showed improvement
very early on in treatment: as early as the first four sessions.
It is not easy to evaluate any form of psychological treatment, especially one as complex and ambitious as cognitive therapy. It is encouraging, however, that some careful and well-conducted research has already yielded promising results. It is perhaps still too soon to arrive at
anything more than a general endorsement of the promise of the therapy
at this stage: It seems that cognitive therapy can be effective in modifying depressive symptomatology, particularly depressed mood, although
its effectiveness in producing lasting or more fundamental cognitive
change has yet to be established.
III. CRITICAL APPRAISAL OF BECK'S COGNITIVE THERAPY
Any critique of cognitive therapy must be tempered by two considerations: First, due recognition must be paid to Beck for the major contribution he has made to the understanding and treatment of depression. In a
short space of time cognitive therapy has emerged as a radical alternative to existing treatments and is already attracting a considerable following. Second, it must be averred that any attempt to understand
depression will necessarily be incomplete. Not only does dispute remain
about what depression is or is not, but the current state of knowledge is
such that one can do no more than speculate in many areas.
This critical appraisal is motivated by a mixture of reactions to cognitive therapy. One immediate reaction was that of excitement and interest in what appeared to be a highly promising and attractive therapy,
one that combined the practical hardheadedness of behavior therapy
Changes in Depressive Beliefs
99
with the recognition of the full and important part that cognitions play
in emotional disorders. A later reaction, which came after more careful
study of the therapy as well as some supervised experience of its use,
was one of a certain skepticism about some of Beck's claims, in particular the fundamental rationalism of the approach and the claim made for
achieving changes in underlying assumptions or beliefs. These will be
my two major criticisms of Beck's cognitive therapy.
A. The Cognitive Model of Depression Revisited
A cornerstone of the cognitive model of depression is the assertion
that cognition is the prime cause of the depressive syndrome. For example,
The other signs and symptoms of the depressive syndrome may be viewed as consequences of the activation of the negative cognitive patterns. (Beck, 1983)
The theory makes a clear causal relationship between cognition, behavioral, affective
and physiological disturbances. The theory goes beyond descriptive detailing of the
experience of depression and asserts that cognitions cause and maintain the depressive syndrome. (Rush & Giles, 1982, p. 151)
The question of causation is a tricky one since theorists differ in the
ways they conceptualize both causation and depression. Beck (1983)
takes care to reject any notion of ultimate causation. He is not looking for
a single factor that will in some mysterious way "explain" all depression. Indeed, the search for an "ultimate cause" would be a lengthy and
fruitless one since depression is not itself a discrete entity, but a constellation of behaviors and symptoms.
There is a sense in which the cognitive model of depression elevates
cognition to a position of central importance in the process of becoming
depressed. As was illustrated in Fig. 1, it begins with the "cognitive
triad" and all other symptoms of depression (mood, behavior, somatic
sensations, etc.) follow. In this model negative thinking is the prime
cause of depression because it precedes other symptoms. Depressed
mood, in particular, arises from patterns of negative thinking. Teasdale
(1983) carefully and studiously discussed the relationship between negative thinking and depressed mood, drawing upon many of his own
experimental studies on mood induction. There is no doubt that these
experimental studies have convincingly demonstrated that inducing
negative thinking in both nondepressed volunteers and depressed patients leads to predictable changes in mood. However, it is also true that
inducing mood changes (e.g., by listening to music) results in changes in
thinking. A reciprocal relationship between negative thinking and
mood is in fact best supported by the available evidence.
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Thus, negative cognitions appear to produce depression, and, conversely, depression
increases the probability of just those cognitions which will cause further depression.
This reciprocal relationship between depression and cognition may form the basis of a
vicious cycle which will perpetuate and possibly intensify depression. (Teasdale,
1983, p. 23)
If negative thinking and depressed mood interact in this "vicious
cycle" manner, in what sense is it true to say that negative thinking is
the prime cause of depression? Or should we agree with Coyne (1982)
that "there are difficulties in rigidly adhering to a paradigm in which
cognition is an entity causally antecedent to other psychological processes"? Cognitive therapists may be eager to ascribe primacy to cognition since this is the rationale for a therapy which seeks to modify and
change cognitive processes. In practice, depressed patients are taught to
recognize maladaptive thought processes and thereby begin the process
of change. Yet it may simply be more convenient to intervene by focusing on negative thinking and thereby "break in" to the vicious cycle.
Moreover, cognitive therapy does not always begin with cognitive
change. In the case of severely depressed patients, for example, Beck et
al. (1979) advise a structured behavioral program of increased activities
as the strategy of choice. Emotional factors also play a part as in the view
that a warm and trusting relationship facilitates change.
Therefore, the emphasis on causal primacy for cognition is perhaps no
more than a way of highlighting its importance in the process of becoming depressed. Zajonc's (1980) critique challenged the simplistic assertion that cognition was a universal cause of affective processes. The
debate that followed concerning the relative importance of cognition to
emotions (e.g., Greenberg & Safran, 1984; Lazarus, 1982; Mahoney, 1984;
Rachman, 1981) has been partially resolved by an agreement between
most theorists that a dynamic interdependence between thought, feeling, and action describes their relationship more usefully than any assertion of primacy, viz.,
Both sides of the debate are in agreement that affect and cognition can be, indeed
usually are, interconnected. Furthermore, both sides agree that the interactions between affect and cognition can go in either direction. Neither side takes the view that
there is a unidirectional causal influence. (Rachman, 1984, p. 582).
This recognition of interdependence rather than prime causation
should apply to cognitive therapy too. While this should make little
difference to the practice of the therapy, it may help to correct an excessive emphasis on cognitive determinants in the theory.
Changes in Depressive Beliefs
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Β. Schemas Revisited
Central to the cognitive model of depression and to cognitive treatment is the notion of schema. Beck uses this concept to explain the
organization of thought processes and their stability and consistency
over time. "A schema is a structure for screening, coding, and evaluating the stimuli that impinge on the organism. It is the mode by which the
environment is broken down and organized into its many psychologically relevant facets" (Beck, 1967, p. 283). In his analysis of depression,
Beck postulates that "depressogenic schémas" are formed as a result of
unhappy childhood experiences, and from beliefs or "rules" that are
transmitted from parents to children. They may remain dormant in the
adult until reactivated by events or experiences that are similar to those
which led to their original formation.
Depressogenic schémas have the following attributes. They are (1)
idiosyncratic, (2) maladaptive, (3) distortions of or deviations from reality, (4) rigid and extreme, and (5) implicit, unarticulated, and unexamined. In depression these idiosyncratic schémas are strongly activated
and displace other more objective schémas, producing cognitions that
are "exceptionally compelling, vivid, and plausible" and resulting in
the cognitive errors listed earlier. In this way a depressed person comes
to believe extreme, negative, and unrealistic ideas (e.g., "I am a complete failure") and to organize his thinking in such a way that his experience confirms him in this extreme judgment. Cognitive therapy aims to
show the depressed patient the distorted nature of these schémas and
substitute more realistic schémas in their place.
Beck (1976) listed several beliefs or rules which he believed characterized depressive thinking.
1. In order to be happy, I have to be successful in whatever I undertake.
2. To be happy, I must be accepted by all people at all times.
3. If I make a mistake, it means that I am inept.
4.1 can't live without you.
5. If somebody disagrees with me, it means he doesn't like me.
6. My value depends on what others think of me.
Taken literally these rules or prescriptions are obviously extreme,
almost certainly maladaptive, and in most instances wrong. For example, someone can disagree with you and still like you. It is possible to be
happy and unsuccessful. Making one mistake does not necessarily mean
that you are generally inept. A strong point of cognitive therapy is that it
encourages depressed patients not to accept these rules at face value,
but to test out the evidence, to list the pros and cons, to examine them for
examples of cognitive errors such as overgeneralization, and even to
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behave in a way that is directly counter to the prescribed rules while
observing the consequences.
However, in taking this literal approach, there is a real danger of the
cognitive therapist "not seeing the forest for the trees." A depressed
person may verbalize the thought "To be happy, I must be accepted by
all people at all times" and rate this thought as highly believable. But
what he may mean is not the literal meaning, that all people must accept
him at all times, which would be absurd, but that this thought encapsulates the extremely high value he places on acceptance by others and
the dread he has of possible rejection. It is the personal value implicit in
the statement, not its literal meaning, that is important. Similarly, the
statement "If I make a mistake, it means that I am inept" encapsulates
the enormous personal value placed upon achieving perfection and the
dread of failure, rather than the literal truth that any mistake in whatever context automatically means that one is an inept fool. Depressed
people, like all of us, are able to discriminate the trivial errors from the
more "serious" ones (e.g., dialing the wrong number can be seen as a
minor form of carelessness and forgotten pretty rapidly, but forgetting a
close colleague's name when about to introduce him to another acquaintance can cause embarrassment and self-criticism that may reverberate for weeks).
It may be true, as Beck suggests, that many depressed people "catastrophize," magnify, and overgeneralize, with the result that what appear as relatively trivial and unimportant errors to most people are
interpreted as yet more signs of personal weakness and inadequacy.
Depressed people are highly sensitive to personal failure. But this is not
the same as taking the verbal expression of deeply held beliefs and
values as the literal truth.
The challenge made by cognitive therapy to established beliefs by
procedures such as examining the evidence and listing the pros and
cons may have an effect not because such beliefs are illogical, irrational,
or unrealistic, but because they open up the possibility of choice. Perhaps for the first time a depressed patient is asked to consider that what
he or she has taken as a God-given truth may in fact be misguided or
even harmful. It is not, therefore, whether the statement "If I make a
mistake, it means I am a complete failure as a person" is literally true or
false that is important, but a recognition that the extremely high value
placed upon perfection is not the only possible way of leading one's life.
It is not the illogicality of the belief that is important, but the simple fact
that alternative beliefs can be of equal or greater value. This is to suggest
that cognitive therapy, while directing its energy at the right target
(dysfunctional beliefs), is shooting the wrong bullets: It is not logic that is
Changes in Depressive Beliefs
103
of use, but value. This argument is made most plausibly in Rowe's
analysis of depressed people's beliefs.
IV. ROWE'S PERSONAL CONSTRUCT THERAPY
2
Rowe is a clinical psychologist and a personal construct psychotherapist who developed an approach to depression directly from her experiences with depressed people. Her therapeutic approach and style are
different from those of Beck and other cognitive therapists. Her approach places a greater emphasis on personal experience and on the
personal relationship of patient and therapist. However, there are some
similarities with cognitive therapy, particularly in the focus on underlying cognitive distortions as a central factor in depression. Rowe departs from Beck's cognitive therapy in the way that she characterizes
the types of beliefs that dominate depressive thinking and in the way
that she seeks to induce change in those beliefs.
A. Rowe's Model of Depression
According to Rowe, each person has his own unique experience of
depression which reflects his personal construction of the world.
Each of us, through our individual language, through a system of constructs arising
from reason, metaphor and myth, structures and evaluates our individual world. The
world we create is a world of meaning. Everything we perceive has a meaning. (Rowe,
1978, p. 25)
This is very much the constructivist position and one that is very close to
Beck's:
The thesis that the special meaning of an event determines the emotional response
forms the core of the cognitive model of emotions and emotional disorders. (Beck,
1976, p. 52)
Beck, however, refers primarily to the conscious meaning that an individual gives to a stimulus or event. Rowe, in contrast, suggests that the
depressed person's construction of the world may be both conscious and
unconscious. In his construction of the world the individual imposes a
pattern upon it and so gives it meaning.
Our world is completely intelligible, completely meaningful. Parts of it may, at times,
seem unpredictable, irrational, unintelligible, meaningless, but unintelligibility and
meaninglessness are themselves meanings. We are encapsulated in a world of meaning, constructed through our senses and our talents to create form. (Rowe, 1982, pp.
2-3)
2
Her most recent book, Depression. The Way out of Your Prison, is written directly for
depressed people and was awarded MIND "Book of the Year, 1983," by the National
Association for Mental Health in the United Kingdom.
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The construction can be expressed in many ways, the commonest of
which is language. We learn to label our experience. Depression itself is
a good example of such labeling. Psychiatrists and psychologists learn to
use the label of "depression" to describe certain experiences of others
(and, sometimes, themselves). For some, depression implies a biologically determined disturbance of mood which is amenable to treatment
by antidepressant medication. To others depression describes a subjective feeling of unhappiness which is a product of a person's experiences
in life and, more particularly, their personal construction of those experiences. These different models of depression are, in fact, metaphors.
The medical model with its emphasis on biological disturbance seeks to
describe the experiences of depressed people in the metaphor of illness.
The cognitive model, on the other hand, uses the metaphor of the creation of form and pattern: The clue to the experience of depression lies
in the way experience is patterned by the individual. To Rowe the
metaphor used by the depressed person is all important.
If we are to understand another person we must seek to understand his metaphors.
(Rowe, 1978, p. 21)
Although each individual's experience of depression is unique, there
are common themes. These are expressed in the metaphor of the prison
and, in particular, isolation from other people.
It is this peculiar isolation which distinguishes depression from common unhappiness. It is not simply loneliness, although in the prison of depression you are pitifully
alone. It is an isolation which changes even your perception of your environment.
Intellectually you know that you are sharing a space with other people, that you are
talking to them and that they are hearing you. But their words come to you as if across
a bottomless chasm, and even though you can reach out and touch another person, or
that person touches you, nothing is transmitted to you in that touch. No human
contact crosses the barrier. Even objects around you seem further away, although you
know it is not so, and while you are aware that the sun is shining and the birds are
singing, you know, even more poignantly, that the colour has drained from the sky
and the birds are silent. (Rowe, 1983, pp. 1-2)
What brings about this state of terrible isolation? Rowe's model of
depression suggests that the individual constructs the isolation himself.
He builds his own prison. She suggests that building blocks are a set of
opinions that come to be held as real, absolute, and immutable truths.
These are contained in six basic propositions.
1. No matter how good or nice I appear, I am really bad.
2. Other people are such that I must fear, hate and envy them.
3. Life is terrible and death is worse.
4. Only bad things happened to me in the past and only bad things will happen to me
in the future.
Changes in Depressive Beliefs
105
5. It is wrong to get angry.
6.1 must never forgive anyone, least of all myself. (Rowe, 1983, pp. 15-16)
Although these propositions are slightly different from the six rules
that Beck (1976) listed, they have some attributes in common. They are
examples of extreme thinking [e.g., "I can't live without you" (Beck); "It
is wrong to get angry" (Rowe)]. They are self-punitive [e.g., "If I make a
mistake, I am inept" (Beck); "I must never forgive anyone, least of all
myself" (Rowe)]. And they paint a gloomy view of the world and the
future ["To be happy, I must be accepted by all people at all times"
(Beck); "Only bad things happened to me in the past and only bad things
will happen to me in the future" (Rowe)]. In this respect, Beck's description of depressive thinking in terms of the negative triad accurately
portrays the characteristic cognitive style of depressed people as both he
and Rowe have described. The main difference lies in Rowe's emphasis
on the depressed person's notion of essential badness. Beck, on the other
hand, describes the way a depressed person's sense of self-worth depends upon social success and acceptance by others. These attributions
are of course not contradictory: If you see yourself as essentially bad, it is
virtually impossible for other people to like you. If they do, there must
be something wrong with them!
Thus far, the cognitive and personal construct models of depression
are strikingly similar in their description of depressive thinking. A
major difference, however, lies in their interpretations of the nature of
depressive beliefs. This is encapsulated in the distinction made by Rowe
between metaphysical and rational beliefs.
B. Metaphysical and Rational Beliefs
Rowe describes the different types of belief as follows:
The main differences between metaphysical and rational beliefs seem to be in their
capacity of proof and the ease with which they are given up. Rational beliefs are
capable of proof, and when disproved can be relinquished. Metaphysical beliefs do
not lend themselves to proof, not in this world at least, and, once held, are not easily
relinquished. (Rowe, 1982, p. 47)
To Rowe it is metaphysical, not rational, beliefs that are central to the
depressed person's construction of the world. They are the "core constructs . . . axes on which our individual world turns." These are beliefs which are held with such great conviction that empirical evidence
or reasoned argument fails to shake them. Religious beliefs fall into this
category. A belief in God is often described as a matter of faith. It is not
amenable to change by, for example, arguments about the arbitrariness
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John S. Marzillier
of nature or evidence about the evils that exist in the world. In contrast,
certain beliefs are entirely rational and can be disproved by empirical
evidence. For example, the belief that a certain fertilizer is more effective than another in promoting plant growth can be tested by careful
experiment. The evidence will confirm or disconfirm the belief. Scientific inquiry is of course founded upon this method of rational experimentation.
Rowe's view is that the fundamental beliefs of depressed people are
metaphysical and not rational. Consider, for example, the depressed
person who holds very strongly to the belief "Never make a mistake or
show a flaw" (see Beck et αϊ., 1979, pp. 2 6 2 - 2 6 3 ) . If a person holds this
belief with conviction as an absolute truth, then no amount of demonstration that, for example, making a mistake does not lead to rejection,
or logical argument that it is impossible for anyone to be perfect in every
respect, will shake that conviction. This is because the belief is a statement of certain fundamental values held by the person as a matter of
faith. As stated earlier, it is not the literal truth of the belief that is
significant, but its personal value. This distinction is most obvious in
moral and religious codes. "Honour thy father and mother" and "Love
thy neighbor as thyself" are biblical commandments. They cannot be
justified by reference to empirical evidence (e.g., it has been proven that
you will be a happier person if you honor your father and mother), nor
are they shaken by counterevidence (e.g., people who love their neighbors as themselves are, on the whole, more likely to get into neighborhood disputes). These are prescriptions about how to lead one's life and
are "true" regardless of evidence. Rowe takes the view that the beliefs of
depressed people equally are moral commandments which determine
how they should lead their lives. "It is wrong to get angry," "I must
never forgive others," "Other people are to be feared" are in effect codes
of conduct. Rowe believes that these codes stem from the depressed
person's core belief of his/her own essential badness. Seeking good
opinions of others will not work since the belief is held as a matter of
faith rather than subject to reason.
This is not to say that depressed people do not also hold rational beliefs
which can be changed by means of hypothesis testing and checking out
the evidence in the way Beck has suggested. For example, a depressed
patient failed to get a renewal of his membership of a tennis club and
concluded that for some reason he had been rejected as personally
unsuitable. It was possible to check out the truth of this belief by contacting the club and inquiring about his membership. In doing so he
discovered that there had been a delay in getting the renewal of membership cards from the printers and this was responsible for his failure to
receive a card. The belief that he was rejected as unsuitable could be
Changes in Depressive Beliefs
107
assessed and changed by rational means. However, while it is possible to
change certain beliefs by rational means, other more fundamental beliefs will not easily change. The patient's belief that he was an inadequate person whom others did not value or respect was not shifted by
the rational demonstration about the renewal of his membership in the
tennis club. He was in effect saying to himself "O.K. it was not true in
that case that I had been rejected as personally unsuitable for the club,
but I'm sure people believe that of me!" The evidence is discounted
since the conviction of his personal inadequacy overrode any rational
demonstration or argument.
The purpose of metaphysical beliefs is, according to Rowe, to restore a
sense of proportion with which we can live.
Whether we believe in a God in whose hands the universe rests, or in science through
whose powers the secrets of the universe are revealed, we can put ourselves in those
hands or share those powers, and so give ourselves a measure of security. The idea
that we are in some way related to a great power, be it God or science, is essential to
our vanity, and vanity is essential to the survival of human beings in this world.
(Rowe, 1982, p. 49)
Their beliefs provide depressed people with a strong sense of certainty.
("I know life is meaningless whereas most people assume it has a meaning" or "I know that I am fundamentally bad, at least in that way I am
honest about myself.") Because life is meaningless and one is bad, depression is inevitable. It is the exemplification of all that is fundamentally believed about oneself and the world. It would be surprising if one
were not depressed.
C. Changing Beliefs
If you believe that you are essentially bad, evil, unacceptable to yourself and other
people, if you fear other people, if your philosophy of life makes you fearful and
pessimistic, if you are reconciled to your past and you fear the future, if you believe
that anger is bad and if you never forgive, then such beliefs and actions that follow
such beliefs will cause you pain. The only way to stop the pain is to change your
beliefs. (Rowe, 1983, pp. 161-162)
But how do metaphysical beliefs change? The simple answer is that
they do not change easily. Nor are they responsive to direct attack or
practical solutions.
This is an aspect of depression which I think is the hardest thing for any therapist to
try and shift in anybody. It is quite easy when a person is suffering the pain of
depression for the therapist to offer all sorts of acceptable advice about getting rid of
the pain. But when the therapist starts to make suggestions which involve not only
losing pain but the status, the difference that goes along with it, then a therapist starts
to make an attack on the vanity of the person, this is when the person says "No, I don't
want to change." (Rowe, 1978)
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A patient who believed that life was meaningless did not want to
believe anything different and became quite upset when this belief was
challenged in therapy. Her belief in life's essential meaninglessness
helped preserve her in a way of living which, while at times awful and
miserable, justified her banal and unhappy existence. There was no
point in seeking to change anything since in the end there was no
meaning to life. To admit that life had meaning after all would be to lose
this valuable and strongly held belief.
Rowe's therapeutic approach is essentially indirect, and the personal
relationship with the therapist is a major factor.
What one needs in this situation is someone to talk with, someone who will not give
advice and produce solutions, but who will help to unravel the complexities of one's
thinking and feeling and to look at possible alternatives, someone whose presence
ensures that the isolation is not complete. (Rowe, 1978, p. 263)
All this may appear rather vague compared to the armory of procedures
that Beck and his colleagues have developed. However, there are two
features of central importance shared by both approaches. One is the
presentation of the view that there are alternatives to the way of thinking (and also behaving), that there is the possibility of choice. The second
is the role played by the therapist in modeling an alternative value
system and, at least in Beck's cognitive therapy, a way of putting that
value system into practice.
Many aspects of Beck's cognitive therapy suggest to patients the possibility of choice. For example, listing the pros and cons of assumptions
indicates that fundamental beliefs can be viewed functionally and that
alternative beliefs are possible. It is not that patients are told to believe
differently or cajoled to adopt a different set of assumptions. Rather,
simply by listing advantages and disadvantages, the possibility of
change is made evident. In a different way, Rowe seeks to get patients to
unravel what core beliefs mean to them and in doing so illuminate the
potential for change.
You've got three separate ideas . . . you put altogether in one group—love, dependency and fear of rejection. So you can say to yourself if I love somebody I'm dependent on that person and that person will reject me—this is all together in one notion.
But these are three separate things. It is possible to love somebody without any notion
of dependency. That feeling of love is a pleasurable feeling, a warm feeling, a strong
feeling. It goes out towards the other person, it carries a feeling of continuing concern
and interest, but it does not have a feeling of dependency. (Rowe, 1978, pp. 59-60).
Beck et αϊ. (1979) use the idea of assumptions as "personal contracts"
to suggest the possibility of choice. Contracts, after all, can be renegotiated.
Changes in Depressive Beliefs
109
THERAPIST: Do you see how this concept of personal contract applies to your belief
system?
PATIENT: My contract is "If I work hard, people will respect me," and "without
their respect, I can't be happy."
THERAPIST: When did you draw up these contracts?
PATIENT: As we discussed, probably when I was pretty young.
THERAPIST: If you had a business, would you let a child draw up the contracts on
how it would operate?
PATIENT: That is what I seem to have done in my life, and they're contracts that
give controlling interest of the business to others.
Recognition that core beliefs are not necessarily immutable truths is
important. The patient who believed life to be meaningless said on
questioning that she had always believed this to be true. When the
therapist skeptically questioned whether she had believed this immediately after her birth, or indeed in the womb, the patient came to see that
what she had taken as an "eternal truth" might well have been learned
in childhood. If so, perhaps what she had learned may not have been so
wonderful after all. Perhaps there were alternative ways of thinking.
A variety of different therapeutic approaches is possible, each of
which seeks to suggest that there is choice and that fundamental and
strongly held beliefs can be changed. The essential point is that this
should not be conceived as a rational exercise. Nor should it be concerned with literal meanings. Nor should it be a direct attack on such
beliefs since a direct attack will be resisted. Relinquishing value-laden
beliefs is not something that any of us is able to do lightly.
D. Alternative Value Systems
In fact many of the techniques of cognitive therapy are directed not so
much at demonstrating the irrationality of beliefs but either at showing
that the beliefs are maladaptive or explicitly suggesting an alternative
set of values. Thus, the listing of the pros and cons of key beliefs is
concerned not with their rationality but their functional value. The
belief that one should "never make a mistake or show a flaw" can lead to
a state of complete inaction and prevent the patient from achieving
anything at all. This has the positive benefit of avoiding problems and
difficulties, but only at the expense of depression and loneliness. In
tackling such a belief the cognitive therapist may directly suggest an
alternative set of values which he believes to be more acceptable.
THERAPIST: Sometimes it is a good idea to stand one's beliefs on their heads and
see if they make more sense. For example, is it more reasonable to think, "I have to be
imper/ect" than "I have to be perfect?"
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John S. Marzillier
PATIENT: You mean anything worth doing is worth doing poorly?
THERAPIST: Let me ask you — if learning to ski or learning to make friends is worth
doing, is it worth doing poorly?
PATIENT: I guess it would be better than not doing it at all.
THERAPIST: Further, your work habits are not consistent and reasonable. Just
because you soften the demands on yourself, that doesn't mean your work will
become shoddy. Your habits will stay.
PATIENT: What about the idea that I avoid trouble?
THERAPIST: When you avoid a problem you often create others.
Mental health includes a large portion of taking risks.
Is there any way you can avoid all problems?
PATIENT: No. (Beck et αϊ., 1979, pp. 262-263 italics added for emphasis)
The therapist explicitly states his own values, namely that it is better to
take risks than to do little or nothing with one's life. This is underlined in
the authoritative statement "Mental health includes a large portion of
taking risks."
All therapies are built upon a system of values, which may be implicit
or explicit. In cognitive therapy, these values tend to be disguised by
reference to rationalism, objectivity, and a scientific approach. There
are, of course, values in themselves and not given truths (e.g., the assertion that it is better to be objective rather than subjective or that rational
beliefs are superior to religious or metaphysical beliefs). These values
are sometimes very evident and openly acknowledged. Consider this
discussion of "fairness":
The final way of dealing with concern about "unfairness" is to discuss fairness as an
abstraction. There is actually no concrete entity such as fairness. It is a hypothetical
construct, an abstraction. Fairness and unfairness are general terms that no one can
define, yet they can cause great irritation and unhappiness. The therapist can tell
patients that viewing the world in these vague and abstract terms limits their perceptions and thus is often counterproductive. It is better for the person to make a pragmatic judgment as to what he wants and what steps should he necessary to get it. When
the goal seems attainable and worth the effort, he has a better chance of reaching it if
he is not bogged down with concerns about being treated fairly. (Beck et al., 1979, p.
259, italics added)
The values are encapsulated in the statement "It is better for the person
to make a pragmatic judgment as to what he wants and what steps
should be necessary to get it." This endorses pragmatism as a preferred
way of life as opposed to worrying about life's essential unfairness. This
is of course a value judgment. For some people being worried about
unfairness to themselves or to others can be a value that overrides
pragmatic or personal considerations.
Another example can be found in the discussion on happiness.
The arbitrariness of these assumptions is readily apparent when they concern happiness. Many patients believe that if they have Χ (perfection, beauty, fame) they will be
Changes in Depressive Beliefs
111
happy. This formula contains a number of mistaken notions about happiness that can
be discussed. The rules make the "either/or" mistake. Instead of seeing happiness as
a continuum, the patient believes one is either happy or unhappy. The rules imply
that happiness is a static, durable state rather than dynamic and transient. The rules
imply that happiness is a pure state rather than a condition varying in degrees,
including a certain amount of unpleasantness (for example, one can be happy at the
beach, but there are also sand and traffic to put up with). (Beck et αϊ., 1979, p. 269,
italics added)
Whether happiness is a continuum or a dichotomous state is not a
given fact. For some people true happiness may occur only on certain
rare occasions (peak experiences) and people may believe that they
need to achieve fame or discover truth or work diligently to obtain those
rare moments of happiness. This will entail suffering and depression,
but all of this is worthwhile in return for the ultimate reward. The
cognitive therapist, on the other hand, believes in a different notion of
happiness, one that varies in degrees, and there is always the flip side,
the sand on the beach. Misery and depression are self-defeating and
ultimate happiness is illusory. Who is right? There is no way that these
different ideas can be proved true or false. They represent different
systems of value rather than rationality or logic.
V. CONCLUSIONS
This article began with a consideration of the theoretical status of
cognitive therapy. Two of the major claims have been critically examined. With regard to the first—the primacy of cognition in causing
depressive symptoms — it has been argued that the assertion of primacy
is misplaced. Studies of the relationship between negative thinking and
mood have consistently supported a reciprocal rather than a unidirectional relationship (e.g., Teasdale, 1983). Theoretical debate about the
relationship between cognition and emotion may be resolved by postulating the interdependence of these processes rather than the elusive
search for prime causes (Rachman, 1984). The strength of cognitive
therapy lies in the focus on cognition and on methods for cognitive
change. It is suggested that distorted thinking can be viewed not so
much as a prime cause of depression, but as one of the major determinants in the process of becoming depressed.
This view appears close to that adopted recently by Beck (1983).
Firmly rejecting the notion that it is productive to speak of the cause of
depression, Beck suggests that it is more useful to conceptualize depression as the product of a host of possible predisposing and precipatory
factors, which in any given combination can lead to the experience of
depression. Depression is "the final common pathway of many converg-
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John S. Marzillier
ing variables" (Beck, 1983). The activation of negative thinking still
plays a large role in the production of depressive symptomatology, but
the latter is not independent of environmental factors.
A patient slipping into depression may withdraw from significant other people. Thus
alienated, the "significant others" may respond with rejection or criticism, which in
turn, activate or aggravate the patient's own self-rejection and self-criticism. (Alternatively, rejection from others may be the first link in the chain leading to depression.) The resulting negative conceptualizations may lead the patient (who may now
be clinically depressed) to further isolation. Thus the vicious cycle may continue
until the patient is so depressed that he may be impervious to attempts by others to
help him. (Beck, 1983)
These statements explicitly endorse the reciprocal relationship between thinking and behavior in a way that closely parallels Bandura's
notion of reciprocal determinism (Bandura, 1977,1978). Negative thinking is of importance in the way that depression may progressively worsen in a downward spiral of low mood, negative thinking, social withdrawal, etc. It is also useful in therapy to focus on thinking processes as a
means of demonstrating that such a downward spiral may be reversed.
By identifying negative thoughts and modifying them, depressed mood
can be lifted and this in turn can lead to a more positive outlook. The
empirical evidence on the effectiveness of cognitive therapy provides
some support for this process of change. In the study by Teasdale et αϊ.
(1984), most improvement tended to occur in the early stages of the
therapy. This suggests that in this instance cognitive therapy's main
effect occurred by elevating mood rather than by changing beliefs or
assumptions, since the latter is not likely to take place until much later
in therapy. Perhaps the main effect for cognitive therapy lies in helping
patients achieve greater control of depressive thinking and depressed
mood, breaking into the "vicious cycle", and offering practical alternative coping strategies, e.g., distraction, monitoring and counteracting
negative thinking, and increasing pleasurable and mastery activities. It
is of course impossible at this stage of our knowledge to do more than
speculate about the likely mechanisms of change. It would not, however, be a great surprise if the strength of cognitive therapy resided in
the systematic and structured way negative thinking is assessed and
changed since so much of the therapy is specifically geared toward such
thinking.
The second aspect of cognitive therapy examined in this article was
the importance of modifying dysfunctional beliefs. Following the work
of Rowe (1982) a distinction has been drawn between rational and metaphysical beliefs. Rational beliefs are amenable to reasoned argument
and empirical evidence; metaphysical beliefs are not. A major strategy
in cognitive therapy is collaborative
empiricism, in which the therapist
Changes in Depressive Beliefs
113
helps the patient to test his ideas empirically. This is a sensible and
appropriate procedure in the case of rational beliefs. It has the additional
virtue of encouraging patients to engage in activities and thus may
indirectly lead to mood change as positive experiences are encountered.
Like procedures such as distraction for modifying negative thinking,
hypothesis testing is a way of breaking into the vicious cycle of negative
thinking and depressed mood. However, it is not a procedure that is
likely to succeed in the case of metaphysical beliefs, which by definition
are not responsive to reasoned argument or empirical evidence.
Rowe (1982,1983) has suggested that the core constellation of depressive thinking consists of metaphysical beliefs, in particular beliefs about
one's essential badness. Other procedures in cognitive therapy may be
more appropriately directed against such beliefs. Listing the pros and
cons of assumptions, for example, provides an explicit message that
there are alternative belief systems which may have more value to the
individual. In many discussions about beliefs, the therapist models and
sometimes directly states an alternative value system to that of the
patient. The major point is that the process of change in such beliefs is
not a rational one, and in the emphasis on logic and reality testing,
cognitive therapy has not done sufficient justice to other, less rational
means of cognitive change. Rowe further suggests that a direct attack on
metaphysical beliefs is counterproductive because of the enormous
value placed upon such beliefs by the person. There will be resistance to
any attempt to take such beliefs away. There is some danger, therefore,
that collaborative empiricism may backfire precisely because it
threatens very strongly held convictions which may become more entrenched when under attack. The alternative strategy adopted by Rowe
and to a certain extent evident in cognitive therapy is to enable the
patient to unravel the nature of these beliefs to see how much harm
these beliefs cause, to show that they are not immutable nor absolute
truths, and to model and encourage alternative beliefs. It is this aspect of
cognitive therapy that might most usefully be developed further.
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Bandura, A. (1978). The self system in reciprocal determinism. American Psychologist, 33,
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Beck, A. T. (1967). Depression. Clinical, experimental, and theoretical aspects. New York:
Hoeber.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International
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Beck, A. T. (1983). Cognitive therapy of depression. New perspectives. In P.}. Clayton (Ed.),
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Beck, A. T., Rush, A. J., Shaw, Β. F., & Emery, G. (1979). Cognitive therapy of depression.
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Beck, A. T., & Greenberg, R. L. (1974). Coping with depression (a booklet). New York:
Institute of Rational Living.
Blackburn, I. M., Bishop, S., Glen, Α. I. M., Whalley, L. J., & Christie, J. E. (1981). The
efficacy of cognitive therapy in depression: A treatment trial using cognitive therapy
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139, 181-189.
Coyne, J. C. (1982). A critique of cognitions as causal entities with particular reference to
depression. Cognitive Therapy and Research 6, 1-13.
Greenberg, L. S., & Safran, J. D. (1984). Integrating affect and cognition: A perspective on
the process of therapeutic change. Cognitive Therapy and Research 8, 559-578.
Kovacs, M., & Beck, A. T. (1978). Maladaptive cognitive structures in depression. American
Journal of Psychiatry, 135, 525-533.
Lazarus, R. S. (1982). Thoughts on the relation between emotion and cognition. American
Psychologist 37, 1019-1024.
Ledwidge, B. (1978). Cognitive behaviour modification: A step in the wrong direction?
Psychological Bulletin 85, 353-375.
Mahoney, M. J. (1984). Integrating cognition and affect: A comment. Cognitive Therapy
and Research 8, 585-589.
Miller, R. C, & Berman, J. S. (1983). The efficacy of cognitive behavior therapies: A
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Rachman, S. (1981). The primacy of affect: Some theoretical implications. Behaviour
Research and Therapy, 19, 279-290.
Rachman, S. (1984). A reassessment of the "primacy of affect." Cognitive Therapy £r
Research, 8, 579-584.
Rowe, D. (1978). The experience of depression. New York: Wiley.
Rowe, D. (1982). The construction of life and death. New York: Wiley.
Rowe, D. (1983). Depression. The way out of your prison. London: Routledge & Kegan Paul.
Rush, A. J., Beck, A. T., Kovacs, M., & Hollon, S. (1977). Comparative efficacy of cognitive
therapy and pharmacotherapy in the treatment of depressed outpatients.Cognitive
Therapy Research, 1,17-37.
Rush, A. J., & Giles, D. E. (1982). Cognitive therapy: Theory and research. In A. J. Rush (Ed),
Short-term psychotherapies for depression. New York: Guilford.
Shaw, B. F. (1977). Comparison of cognitive therapy and behavior therapy in the treatment
of depression. Journal of Consulting and Clinical Psychology, 45, 543-551.
Teasdale, J. D. (1983). Negative thinking in depression: Cause, effect, or reciprocal relationship? Advances in Behaviour Research and Therapy, 5, 3 - 2 5 .
Teasdale, J. D., Fennell, M. J. V., Hibbert, G. Α., & Amies, P. L. (1984). Cognitive therapy for
major depressive disorder in primary care. British Journal of Psychiatry, 144, 4 0 0 406.
Zajonc, R. (1980). Feeling and thinking. American Psychologist, 35, 151-175.
Dysfunctional Attitudes and a SelfWorth Contingency Model
of Depression
NICHOLAS A. KUIPER
Department of Psychology
University of Western Ontario
London, Ontario, Canada, N6A 5C2
L. JOAN OLINGER
Department of Psychology
Brescia College
London, Ontario, Canada, N6G 1H2
I. Introduction
II. A Self-Schema Model of Depression
A. Content Distinctions
B. Consolidation Distinctions
C. Summary of the Self-Schema Model
III. The Interactive Nature of Depression Etiology:
Dysfunctional Cognitions and Negative Life Events. . .
A. Cognitions and Causality
B. Cognitive Vulnerability to Depression
C. Contractual Contingencies and Depression
IV. A Self-Worth Contingency Model of Depression
Overview of the Model
V. A Closer Look at the Self-Worth Contingency Model. .
A. Etiological Issues
B. Etiological and Maintenance Issues
C. Remission and Treatment Issues
VI. Concluding Comments
References
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ADVANCES IN COGNITIVE - BEHAVIORAL RESEARCH
AND THERAPY, VOLUME 5
Copyright © 1986 by Academic Press Inc
All rights of reproduction in any form reserved.
116
Nicholas A. Kuiper and L. Joan Olinger
I. INTRODUCTION
Depression is a major problem affecting a sizable percentage of individuals in our society. Epidemiological work by Costello (1982), for
example, has found that 27% of a random survey of over 400 women in
Calgary, Alberta, qualified as either definite or threshold cases of depression. Similar results have been obtained by surveys in other locales.
In Britain, Brown and Harris (1978) reported that 3 6 % of their sample of
females represented either definite or probable cases of depression. In
the United States, Amenson and Lewinsohn (1981) found that fully 4 8 %
of the males and 6 2 % of the females in their sample reported a prior
episode of depression. Furthermore, 3 8 % of the 998 individuals in this
sample indicated that they had received some form of treatment for
depression.
Given the pervasive nature of this problem, depression researchers
have expended considerable energy exploring the various facets of this
disorder. A number of investigators, for example, have described the
cognitive, emotional, motivational, behavioral, and vegetative aspects
of depression (Carson & Adams, 1981; Cook, 1980). Cognitive components relate to factors such as a negative view of self, perceptions of
hopelessness, loss of self-esteem, guilt, and self-castigation (Beck, 1967).
The emotional components of depression refer to feelings of dysphoria,
anxiety, and sadness. Motivationally, the depressed individual is characterized by a lowered activity level and lethargic responding. Behaviorially, the depressed individual often displays poor coping and social
skills, a lack of assertion, and withdrawal from social interactions (Billings & Moos, 1983). Finally, the depressed person is often characterized
by the presence of somatic complaints, such as irregular sleeping and
eating patterns.
Especially prominent in the last decade has been the tremendous
growth in research on cognitive and psychosocial aspects of depression.
A number of theoretical orientations have been elaborated and empirically tested, including Beck's cognitive model of depression (Beck,
Rush, Shaw, & Emery, 1979; Beck & Epstein, 1982), the reformulated
learned helplessness model (Miller & Seligman, 1982), and several psychosocial integrative models (Costello, 1982; Brown & Harris, 1978; Billings & Moos, 1983). Even more recently, there has been a merger of
theoretical interests in the social cognition and depression domains
(Kuiper & Higgins, 1985). Here, several investigators have pointed to the
significant advancements in clinical research and treatment which
have stemmed from this integration (Hollon & Kriss, 1984; Kuiper &
MacDonald, 1983). Although some caution is certainly warranted
(Coyne & Gotlib, 1983), it seems reasonable to conclude that the past
Depression and Self-Worth Contingencies
117
decade has witnessed substantial progress in terms of our understanding of cognitive and psychosocial aspects of depression.
In light of this progress, the purpose of this article is to outline several
aspects of our research program which have focused on social cognition
factors relating to depression. The first phase of our program has explored the nature of self-referent information processing in normal and
depressed individuals. Across a number of empirical studies we have
developed a self-schema model of depression. This model relates the
severity of depressive symptoms to the type of content (positive or negative) represented in an individual's self-schema. This model also highlights the importance of the degree of organization or consolidation of
that information. This article provides a brief overview of the key elements of this self-schema model, and then moves on to a more detailed
consideration of etiological issues relating to depression. This second
phase of our research program is based upon a theoretical model of
depression first proposed by Olinger (1984). In her model, Olinger documented how certain negative life events may interact with a cognitive
vulnerability to depression to produce depressive symptoms. The empirical data associated with this interactive model are presented in this
article, along with several theoretical and empirical elaborations. In
general, it is proposed that perceptions of self-worth play a fundamental
role in the etiology, maintenance, and remission of depressive symptoms. In addition to incorporating the self-schema model of depression,
this self-worth contingency model also considers the interaction of cognitive vulnerability factors and significant negative life events to produce depression.
II. A SELF-SCHEMA MODEL OF DEPRESSION
An often-cited feature of depression is a negative view of self (Beck,
1967). In order to examine this aspect of depression more closely we
have defined the self as a cognitive structure or schema (Kuiper, MacDonald, & Derry, 1983). The self-schema is an organized memory structure containing representational self-referent material, and is centrally
involved in the interpretation, organization, and memory of personal
information. Early work in the social cognition domain has indicated
that self-referent processing of personal material facilitates subsequent
recall of that information (Rogers, Kuiper, & Kirker, 1977). In this work,
subjects made a series of judgments concerning a list of personal adjectives (e.g., capable, sociable). Some of these judgments were self-referent in nature ("Does this adjective mean the same as a given word?"). On
a subsequent incidental recall test, memory performance was clearly
superior for adjectives given a prior self-referent judgment. In turn, this
Nicholas A. Kuiper and L. Joan Olinger
118
finding suggests that the schematic nature of the self provides the most
elaborate encoding and retention of personal information in memory.
In applying this self-schema notion to depression we have introduced
two modifications. As shown in Table I, the first modification concerns
the introduction of a content distinction for self-schema material. As
such, some of the personal adjectives employed in the self-referent
incidental recall paradigm now pertain to positive or nondepressed content (e.g., orderly, helpful), whereas others pertain to negative or depressed content (e.g., hopeless, inferior). A second modification relates
to an increased emphasis on the organizational aspects of the selfschema. Accordingly, some of the studies described below also included
a measure of the degree of organization or consolidation of self-schema
content.
TABLE I
Self-Schema Components for Normal and Depressed Individuals
Self-schema component
Type of
individual
Type of
0
content
Normals
Positive
Mild depressives
Positive and
negative
Clinical
depressives
Negative
α
15
Degree of consolidation
Strong—normals display a highly organized and
cohesive positive self-schema. This well-integrated
schema processes positive self-referent material in
an efficient and consistent manner
Weak—mild depressives display some confusion and
uncertainty about the validity of their own positive
and negative attributes. As such, their self-schema
is poorly integrated and lacks cohesion. Processing
of both positive and negative self-referent material
is inefficient and inconsistent
Strong—clinical depressives display a well-organized,
cohesive and stable negative self-schema. As such,
they are efficient and consistent in processing
negative self-referent material
Type of content can be empirically measured in two ways. One measure consists of the
number of self-referent "yes" responses to nondepressed and depressed content personal
adjectives. A second measure assesses recall for these adjectives.
b
Degree of consolidation consists of two interrelated components: efficiency and consistency. Efficiency can be measured via rating times for self-referent judgments. Consistency can be determined by calculating the percentage of agreement between two sets of
self-referent judgments.
Depression and Self-Worth Contingencies
119
A. Content Distinctions
Several of our studies have explored the type of content represented
in the self-schemata of normals and depressives. Deny and Kuiper
(1981), for example, employed the modified version of the self-referent
incidental recall paradigm with severe clinical depressives and nondepressed controls. After providing y e s / n o self-referent judgments for a
list of depressed and nondepressed adjectives, these subjects were unexpectedly asked to recall as many of these words as possible. It was
predicted that adjectives congruent with the type of content represented in a self-schema would be better recalled than adjectives incongruent with an individual's view of self. In confirmation of this prediction, Derry and Kuiper reported that clinical depressives displayed
enhanced self-referent recall only for depressed content adjectives.
Nondepressed controls, on the other hand, showed enhanced self-referent recall only for nondepressed content adjectives. A similar pattern
was found for the y e s / n o data, with clinical depressives primarily endorsing depressed or negative content words, and normals primarily
endorsing nondepressed or positive content adjectives. This latter pattern was replicated in a further clinical study by MacDonald and Kuiper
(1984). As such, these findings suggest that the self-schema of clinical
depressives consists primarily of negative content, whereas the selfschema of normals consists primarily of positive content.
Additional research using this paradigm has established the effects of
milder levels of depression on self-schema content. Both Kuiper and
MacDonald (1982) and Kuiper and Derry (1982) had normals and mildly
depressed individuals make self-referent judgments concerning the depressed and nondepressed content adjectives. Consistent with prior research, the normal controls in both of these studies recalled far more
nondepressed than depressed adjectives. Again, this pattern suggests a
positive content base for the self-schema of normal individuals. The
mild depressives in both of these studies, however, displayed equivalent
self-referent recall for both types of content. In turn, this latter finding is
consistent with the proposal that both positive and negative content are
represented in the self-schema of mild depressives.
Β. Consolidation Distinctions
A second component of the self-schema model pertains to the degree
of consolidation of the represented self-referent material. Consolidation
can be thought of as the degree of cohesiveness or integration of selfschema content. A well-integrated and cohesive self-schema would process relevant personal material in both an efficient and consistent manner. A poorly consolidated self-schema, however, would display
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Nicholas A. Kuiper and L. Joan Olinger
precisely the opposite effect, leading to the inefficient and inconsistent
processing of personal information.
Several of our studies have used a rating time measure to focus on the
efficiency aspect of consolidation. Kuiper and MacDonald (1982) used
rating times (RTs) for the self-referent yes/no judgments as an index of
schematic processing efficiency. For normals it was found that schemacongruent positive information was processed more efficiently (with
quicker RTs) than schema-incongruent negative information. Similar
RT findings have been reported for the normal controls in other self-reference studies (Derry & Kuiper, 1981; MacDonald & Kuiper, 1984). Mild
depressives, however, do not appear to display efficient processing for
either type of personal content. As one illustration, Kuiper and MacDonald (1982) found that mild depressives displayed extremely long
RTs for self-referent judgments concerning either positive or negative
content. In combination with their recall data, this RT pattern points to a
view of self in mild depressives which incorporates both positive and
negative content, but at the expense of efficient processing of either.
Finally, clinical depressives appear to display efficient processing, but
only for self-referent negative material. MacDonald and Kuiper (1984),
for example, found that clinical depressives processed self-schema congruent material (e.g., negative content) more quickly than incongruent
material (e.g., positive content). Similarly, Derry and Kuiper (1981)
found that clinical depressives were no slower in their self-referent
judgments than normal controls. In turn, these findings suggest that
both clinical depressives and normals employ a well-organized and
cohesive self-schema to assist in self-referent judgments, albeit for negative and positive content, respectively.
One study explored the consistency aspect of self-schema consolidation in clinical depressives (MacDonald & Kuiper, 1984). In part one of
this study, clinical depressives and nondepressed controls made a series
of yes/no self-referent judgments on the depressed and nondepressed
content adjectives. In part two, they rated each adjective on a 9-point
degree-of-self-reference scale. A consistency score was then calculated
for each subject across these measures. Since self-schema-congruent
content is thought to be better consolidated and organized in memory,
MacDonald and Kuiper predicted greater consistency for this type of
information, compared to incongruent content. This pattern generally
emerged. To take one example, clinical depressives displayed significantly fewer inconsistencies for depressed adjectives given a prior yes
decision (self-schema-congruent content for these individuals), compared to their ratings for depressed adjectives given a prior no decision
(schema-incongruent responding for these individuals). In contrast,
both normal and nondepressed psychiatric controls displayed precisely
Depression and Self-Worth Contingencies
121
the opposite pattern. Decision consistency was markedly lower for depressed adjectives given a prior yes rating (schema-incongruent responding for these individuals), relative to their decision consistency for
the same type of adjectives given a no decision (self-schema-congruent
content for these subjects). Overall, then, this study found that all subjects displayed greater decision consistency for their own self-schemacongruent content, compared to their own schema-incongruent content. For normal controls, this pattern highlights the strength of
consolidation of the positive information represented in their selfschema. For clinical depressives, this pattern highlights the strength of
consolidation of their negative view of self.
C. Summary of the Self-Schema Model
When combined, the data reported in the preceding studies permit
the formulation of a self-schema model of depression. As shown in Table
I, a major tenet of this model is that severity of depression is a central
factor in determining both self-schema content and degree of consolidation. Normal individuals display a strongly consolidated, positive selfschema. Clinical depressives also have a strongly consolidated selfschema, but for negative content only. Mild depressives are distinct in
two ways. First, they display both positive and negative content in their
self-schema. Second, their processing of both types of content is inefficient. This inefficiency stems from a poorly consolidated self-schema,
and reflects uncertainty and confusion surrounding the validity of both
positive and negative self-referent attributes. At milder levels of depression, an individual may begin to recognize and incorporate negative
experiences into the self-schema. At the same time, the individual may
begin to increasingly question the validity of positive self-referent attributes. Together, these two processes reduce the overall degree of consolidation of the mild depressive's self-schema for both positive and negative personal information.
III. THE INTERACTIVE NATURE OF DEPRESSION ETIOLOGY:
DYSFUNCTIONAL COGNITIONS AND NEGATIVE LIFE EVENTS
A. Cognitions and Causality
The self-schema studies presented thus far have been primarily descriptive in nature. In other words, these studies have succeeded in
mapping out the content and consolidation aspects of self-schema functioning at several levels of depression. Whereas this research has provided some cognitive mechanisms to help explain how individuals
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Nicholas A. Kuiper and L. Joan Olinger
might become depressed, it has not focused directly on the possible
etiological role of negative cognitions in depression.
Unfortunately, perusal of the cognitive literature on depression fails
to clarify this etiological issue. Several studies offer indirect evidence
that negative cognitions may be implicated in the etiology of depression,
whereas several others conclude that negative cognitions are merely
concomitants of this disorder. As an example in the former category, a
longitudinal study by Weintraub, Segal, and Beck (1974) found that
negative cognitions were generally more enduring than negative affect.
Similarly, work by Wittenborn and colleagues (Altman & Wittenborn,
1980; Cofer & Wittenborn, 1980) has found that formerly depressed
women exhibit the same negative personality characteristics as currently depressed individuals (e.g., low self-esteem and unhappy outlook). In contrast, a large-scale longitudinal study by Lewinsohn, Steinmetz, Larson, and Franklin (1981) found little evidence that depressive
cognitions are evident before or after depressive episodes. In further
accord with this concomitant proposal, other researchers have also
found that former depressives do not exhibit negative cognitions (Laxer,
1964; Wilkinson & Blackburn, 1981).
The inconsistencies in the above findings may reflect the general
research strategy employed by these investigators. The majority of these
studies has attempted to assess depressive cognitions in formerly depressed individuals, but in the absence of current negative life events or
environmental stressors. Yet, a closer examination of Beck's cognitive
theory of depression suggests that a central etiological feature is the
interaction of dysfunctional cognitions and adverse life events (Beck et
αϊ., 1979; Beck & Epstein, 1982; Olinger, 1984). In particular, Beck has
suggested that negative life events which impinge on dysfunctional
cognitions may engage previously latent negative schemata, and thus
contribute to the onset of depressive symptomatology. Overall, then, a
more appropriate test of the possible etiological role of dysfunctional
cognitions would seem to involve the simultaneous consideration of
relevant life events (Olinger, 1984).
An examination of the depression life events literature leads to the
same general conclusion. In particular, it appears necessary to consider
the interaction of an individual's cognitive processes with ongoing environmental stressors in order to more adequately predict subsequent
depression. Traditionally, the life events literature has considered environmental loss, in one form or another, as a possible cause of depression.
This loss may take the form of death of a parent at an early age, or loss of
love through marital separation, divorce, or death (Beck, Sethi, & Tuthill, 1963; Costello, 1982; Shaw, 1982). A major problem with this literature, however, is that it cannot fully account for cases in which loss does
Depression and Self-Worth Contingencies
123
not result in depression. Several studies have pointed out that only a
minority of individuals who experience loss becomes clinically depressed (Clayton, Halikas, & Maurice, 1972; Paykel, Myers, Dienelt,
Klerman, Lindenthal, & Pepper, 1969). As such, there is a growing
awareness in this area that congnitive processes must also be considered
in determining reactions to life events (Olinger, 1984).
B. Cognitive Vulnerability to Depression
Previous research investigating cognitive aspects of depression has
considered former depressives to be especially vulnerable to depression. This assumption appears empirically valid, as these individuals do
display an increased probability for future episodes (Beck, 1967). It is
also possible, however, to provide a more theoretical definition of vulnerability. In particular, Beck and colleagues (Beck et ah, 1979; Beck &
Epstein, 1982) have proposed that excessively rigid and inappropriate
rules for guiding one's life constitute a cognitive predisposition or vulnerability to depression. These rules, or dysfunctional attitudes, can be
assessed via the Dysfunctional Attitudes Scale (DAS: Weissman & Beck,
1978; Weissman, 1980). The 40 items on this self-report scale were written to reflect the dysfunctional attitudes that Beck has noted in his
treatment of depressed individuals. Responses indicating dysfunctional
beliefs would involve agreement with statements like the following: "If I
do not do well all of the time, people will not respect me," or "If I do not
perform as well as others, it means that I am an inferior human being."
Possible scores on the DAS range from 40 to 280, with higher scores
indicating greater dysfunctional attitudes. Internal consistency coefficients for the DAS range from .79 to .93; with test-retest reliabilities
across a 2- to 3-month period ranging from .74 to .81 (Dobson & Breiter,
1983; Kuiper, Olinger, & Air, 1986a; Weissman & Beck, 1978; Weissman,
1980). In terms of construct validity, depressed individuals are found to
score higher on the DAS than nondepressed controls (Dobson & Breiter,
1983; Gotlib, 1984; Kuiper & Cole, 1983; Vezina & Bourgue, 1984; Weissman & Beck, 1978). In addition, DAS scores are excellent predictors of
subsequent depressive episodes (Eaves & Rush, 1984; Rholes, Riskind, &
Neville, 1985), and the degree of success of therapeutic interventions
(Eaves & Rush, 1984; Hammen, Jacobs, Mayol, & Cochran, 1980; Keller,
1983; Simons, Garfield, & Murphy, 1984). Finally, irrational beliefs
(Ellis, 1962), which are conceptually quite similar to dysfunctional attitudes, have also been used successfully to predict subsequent depression levels (Rohsenow & Smith, 1982; Vestre, 1984).
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Nicholas A. Kuiper and L. Joan Olinger
C. Contractual Contingencies and Depression
According to Beck's cognitive approach, a depressive episode is precipitated when environmental events impinge on an individual's cognitive vulnerability. As such, his model suggests that the emergence of
depressive symptoms is contingent upon the interaction of dysfunctional attitudes and life events. Unfortunately, Beck's model does not
clearly delineate how these events may impinge on a cognitive vulnerability to depression. Olinger (1984), however, suggests that an operational definition could be the individual's failure in fulfilling the contractual contingencies of dysfunctional attitudes. In other words,
individuals with the dysfunctional attitude that self-worth depends
upon the approval of others would likely become depressed if they
believed that others disapproved of them. However, if the individuals
continued to meet the contractual contingencies outlined in their dysfunctional attitudes, then they would likely remain nondepressed. As
one specific illustration, an individual may endorse the dysfunctional
attitude "My value as a person depends greatly on what others think of
me" (DAS Item 19). Embedded within this attitudinal statement is the
contractual condition that self-worth depends strongly on the approval
of others. Thus, if the individual perceives that others think well of her,
she would probably remain nondepressed. On the other hand, if she felt
that others did not think well of her, her contractual conditions for
self-worth would not be met. In turn, this may lead to the development
of further symptoms of depression.
Empirical support for this contractual contingencies proposal was
obtained in a study by Olinger, Kuiper, and Shaw (1986a). In this study,
subjects were administered the DAS, the Beck Depression Inventory
(BDI: Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), and the DASContractual Contingencies scale (DAS-CC). The DAS-CC is a modified
version of the DAS designed by Olinger et aJ. (1986a), to measure the
presence or absence of life events that impinge on an individual's dysfunctional attitudes. For instance, for the dysfunctional attitude "If you
don't have other people to lean on, you are bound to be sad," the contractual contingency for happiness is having other people to lean on. If
the individual reported that h e / s h e had other people to lean on, then
the contractual contingencies of that dysfunctional attitude were fulfilled, and the individual would not likely exhibit depressive symptoms.
If the individual reported, however, that h e / s h e did not have other
people to lean on, then this was considered a failure in fulfilling the
contractual contingencies of this dysfunctional attitude, and the subject
would be expected to show depressive symptoms. Therefore, the situational component of each dysfunctional attitude became the basis for a
new scale, designated the DAS-CC.
Depression and Self-Worth Contingencies
125
Participants in the Olinger et al. (1986a) study were classified as attitudinally vulnerable if they scored above the median on the DAS (a
score of 123) and attitudinally nonvulnerable if they scored below the
median. These participants were simultaneously classified as having
life situations that would negatively impinge on dysfunctional attitudes
if they scored above the median of the DAS-CC (a score of 132), and as
lacking impinging life situations if they scored below the median. As
they expected, Olinger et al. (1986a) found that attitudinally vulnerable
individuals with impinging life situations (e.g., those scoring high on
both the DAS and the DAS-CC), were significantly more depressed on
the BDI than attitudinally vulnerable individuals without impinging
life events (e.g., high DAS but low DAS-CC scores). The BDI means for
these two groups were 13.09 and 5.05, respectively. In further accord
with an interactive approach, the BDI depression scores for the two
nonvulnerable groups (low DAS with either high or low DAS-CC scores),
and the vulnerable group without impinging life events, were all equivalent and below a traditional BDI cutoff score of 9 for depression. The
actual BDI means for these three groups ranged from 3.98 to 6.37. In
summary, then, it was only the interaction of dysfunctional attitudes
with a failure to meet contractual contingencies that produced depressive symptomatology.
IV. A SELF-WORTH CONTINGENCY MODEL OF DEPRESSION
Overview of the Model
The work reviewed thus far has highlighted the importance of both a
negative self-schema in depression, and the interactive nature of depression etiology. As such, these two elements are incorporated in a
self-worth contingency model of depression, as presented in Table II. In
this model, individuals are simultaneously classified according to their
vulnerability and depression levels. A nonvulnerable, nondepressed
individual, for example, would score low on a measure of cognitive
vulnerability to depression (e.g., the DAS), and low on a measure of
current depression level (e.g., the BDI). In contrast, vulnerable nondepressed individuals would score high on the DAS, but low on the BDI. As
such, these individuals would be considered cognitively vulnerable to
depression, but currently nondepressed. Finally, vulnerable depressed
individuals would score high on the DAS and either moderately high on
the BDI (mild depression) or high on the BDI (clinical depression). For
each of these types of individuals, Table II indicates self-schema content
and degree of consolidation, along with associated processes.
A fundamental aspect of the self-worth model pertains to dysfunc-
Nicholas A. Kuiper and L. Joan Olinger
126
TABLE II
A Self-Worth Contingency Model of Depression
Self-schema component
Type of
individual
Nonvulnerable
nondepressed
Vulnerable nondepressed
Vulnerable depressed
(mild)
Vulnerable depressed
(clinical)
Type of
content
Degree of consolidation
Strong—nonvulnerable nondepressed individuals, or normals, exhibit a well-integrated and
cohesive positive self-schema
Weak—vulnerable nondepressed individuals
Positive
are often engaged in assessing their self-worth.
As such, their positive view of self is relatively
fragile and subject to frequent réévaluation.
This results in a poorly consolidated selfschema. The content of this schema is still
positive, however, as these vulnerable
individuals perceive that they are still meeting
their dysfunctional self-worth contingencies
Positive and Weak — vulnerable individuals who no longer
perceive that they are fulfilling their selfnegative
worth contingencies increase coping attempts.
An accompanying increase in self-focused
attention highlights self-blame. In turn,
negative aspects of the self become increasingly incorporated in the vulnerable individual's self-schema. Simultaneously, positive
elements are deemphasized. Further depressive symptomatology follows (e.g., negative
cognitions and affect, self-rejection, social
skills deficits, withdrawal)
Strong—over time, vulnerable individuals'
Negative
coping attempts to reinstate the conditions
necessary for fulfilling their dysfunctional selfworth contingencies may prove unsuccessful.
Once their coping repertoire has been
exhausted, a negative view of self completely
preempts and dominates any positive elements
of the self-schema. As such, this negative
self-schema is highly integrated and cohesive
Positive
tional attitudes. Individuals displaying dysfunctional attitudes are considered vulnerable to depression, whereas individuals not displaying
these attitudes are considered nonvulnerable. In vulnerable individuals, dysfunctional attitudes establish externally based contingencies
for self-worth. In particular, these contingencies relate to an excessive
need for approval from others. As one example, in the attitude, "My
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127
value as a person depends upon what others think of me," the implicit
condition for self-worth is that others think well of this person. If this
person perceives that others did not think well of her, she would likely
evaluate herself as having little worth.
An individual's development and use of dysfunctional attitudes may
reflect, in part, a parenting style that fosters dependency and self-criticism (Burger, 1984; Carver & Ganellen, 1983; McGranie & Bass, 1984). As
one illustration, both Altman and Wittenborn (1980) and Cofer and
Wittenborn (1980) have shown that former depressives exhibit high
levels of narcissistic vulnerability. This exaggerated concern and sensitivity about what others think of you is also a central feature of dysfunctional self-worth contingencies. As such, Wittenborn and colleagues
provide further data to indicate that the development of these concerns
can be traced back to an overly critical mother and dependency-fostering father.
A second fundamental aspect of the self-worth model pertains to
attempts to fulfill self-worth contingencies. When relevant stressor
events hamper the vulnerable individual's ability to fulfill self-worth
contingencies, that person responds by attempting to modify, reduce, or
eliminate these stressors. Mild threats to self-worth frequently occur for
the vulnerable individual, who is highly dependent upon environmental input for self-esteem maintenance. More serious threats to selfworth are expected via the cumulative effects of microstressors, or the
occurrence of highly undesirable macrostressors. Life events that can
provoke a depressive response in a vulnerable person may have their
impact by upsetting the balance of environmental input about one's
abilities to meet self-worth contingencies. Thus, culminating microstressors (such as interpersonal conflicts) may be sufficiently potent to
provoke a depressive episode in a vulnerable person. Alternatively,
depression may be provoked by the occurrence of highly undesirable
macrostressors, such as loss of employment or loss of a significant other.
In any case, it should be noted that all of these events have their impact
through an actual or expected lack of fulfillment of self-worth contingencies. A vulnerable person may be particularily threatened by such
events if h e / s h e lacks, for example, other employment opportunities or
additional sources of social contact.
With each failed attempt to meet self-worth contingencies, an increase in depressive types of responding is expected within the domains
of cognition, affect, behavior, and physiology. These responses may
reach a magnitude sufficient to constitute a depressive episode if the
stressor remains unmodified. During the process of attempting to modify their stressful situations, important changes are expected in the way
vulnerable individuals view themselves, attempt to cope with the
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Nicholas A. Kuiper and L. Joan Olinger
stress, and interact with others. Specifically, vulnerable individuals are
expected to shift from a positive view of self to a negative one. This
change is accompanied by a simultaneous increase in self-focused attention and self-blame. Vulnerable individuals are also expected to rely
increasingly on emotional regulation of their responses to stress, rather
than persisting in direct problem-solving attempts. Finally, vulnerable
individuals are expected to begin to interact with others in a manner
which elicits the rejection they expect. Overall, then, these changes
facilitate the maintenance of a depressive episode by hampering the
vulnerable individual's attempts to fulfill self-worth contingencies.
V. A CLOSER LOOK AT THE SELF-WORTH CONTINGENCY MODEL
The remainder of this article provides a detailed theoretical and empirical examination of the various facets of the self-worth contingency
model of depression. Since this model deals with the entire process of
depression, this examination takes into account etiological, maintenance, remission, and treatment issues. For each of these issues, empirical evidence is brought to bear on the model. Some of this evidence is
indirect, and comes from studies conducted in the social cognition and
depression domains. Other sources of evidence are more direct, and
come from studies conducted in our own laboratory.
A. Etiological Issues
1. An increased Sensitivity to Environmental Information
Due to the presence of dysfunctional attitudes, vulnerable individuals
display an increased concern for self-evaluation compared to nonvulnerable individuals. One form this concern takes is a heightened sensitivity to environmental events that vulnerable individuals view as relevant to the self-worth contingency aspects of their dysfunctional
attitudes. As such, vulnerable individuals monitor and interpret a wide
range of environmental and life events as being highly relevant to their
perceptions of self-worth. Nonvulnerable individuals, on the other
hand, would consider many of these events as being far less central to
their own evaluations of self-worth. The absence of dysfunctional attitudes makes it far easier for the nonvulnerable individual to maintain a
highly consolidated positive view of self. Accordingly, the nonvulnerable individual is far less reactive to the possible self-worth implications
of various life events. This ultimately reduces the probability that nonvulnerable individuals will display depressive symptomatology.
Depression and Self-Worth Contingencies
129
Several lines of evidence converge on the notion that vulnerable
individuals are more sensitive to environmental information than nonvulnerable individuals. As described in Section III, work by Altman and
Wittenborn (1980) and Cofer and Wittenborn (1980) has shown that
former depressives are overly concerned with what others think of
them. Indirectly, then, this finding hints that narcissistic vulnerability
may be one form of increased environmental sensitivity displayed by
vulnerable individuals.
Two studies completed in our laboratory provide more direct empirical evidence. In the first study, Olinger et αϊ. (1986a) had participants
complete the BDI, DAS, and DAS-CC. In addition to documenting the
interactive nature of depression etiology (as described in Section III),
this study also examined the sensitivity issue. In particular, Olinger et
αϊ. (1986a) proposed that attitudinal vulnerabilities may contribute to
heightened levels of self-generated stress. Individuals with dysfunctional attitudes may perceive events within the domain of their dysfunctional attitudes as being more meaningful and having greater emotional impact than individuals without dysfunctional attitudes. Thus,
another purpose of the Olinger et αϊ. study was to determine if those
individuals scoring high on the DAS (attitudinally vulnerable), regardless of their DAS-CC or BDI scores, provided higher stress appraisals of
actual or potential life events than those individuals scoring low on the
DAS (attitudinally nonvulnerable). This predicted pattern of sensitivity
obtained, as subjects with dysfunctional attitudes did evaluate situations as being more personally important, and as having greater emotional impact, than did subjects without dysfunctional attitudes.
A further study by Kuiper and McCabe (1985) also offers some evidence to indicate that vulnerable individuals may exhibit an increased
sensitivity to environmental input and feedback. In this study, vulnerable individuals (those with high DAS scores) showed a greater willingness to discuss negative self-disclosure topics with strangers than nonvulnerable individuals (those with low DAS scores). This finding is
consistent with the notion that vulnerable individuals, regardless of
their current depression level (depressed or nondepressed), tend to seek
out more personal feedback from others than nonvulnerable individuals. In turn, this sensitivity may reflect the vulnerable individual's
enhanced concern with self-worth.
2. Self-Schema Content
A basic tenet of the self-worth model is that a negative view of self is
an episodic marker of depression. In other words, individuals that are
cognitively vulnerable for depression, but currently nondepressed, are
not expected to show a negative-content self-schema. Instead, the self-
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Nicholas A. Kuiper and L. Joan Olinger
worth model predicts that both nonvulnerable nondepressed and vulnerable nondepressed individuals will display positive content in their
self-schemata. As shown in Table II, the critical distinction is that only
the former group exhibits a strong degree of self-schema consolidation.
For vulnerable nondepressed individuals, their positive view of self
reflects the perception that they are currently meeting the self-worth
contingencies of their dysfunctional attitudes. If a vulnerable nondepressed individual interprets an attitude-relevant event as satisfying the
self-worth contingency components of his/her dysfunctional attitudes,
then there is a minimal focus on negative aspects of the self. In turn, this
positive content base mitigates against the development of further forms
of depressive symptomatology. In essence, then, the vulnerable nondepressed person remains nondepressed because h e / s h e perceives that
his/her dysfunctional contingencies for self-worth are being fulfilled.
Research in our laboratory has offered empirical support for the proposal that a negative-content self-schema is an episodic marker of depression. One study by Kuiper, Olinger, MacDonald, and Shaw (1985),
for example, used the self-reference incidental recall paradigm employed in previous research. Consistent with earlier findings, and the
self-schema model of depression, Kuiper et al. (1985) found that nonvulnerable nondepressed individuals (e.g., normals or those scoring low on
both the DAS and BDI) displayed a positive content base for their view of
self. Specifically, these nonvulnerable individuals recalled far more
nondepressed than depressed adjectives given a previous self-reference
judgment. Also in accord with the self-schema model of depression,
vulnerable depressed individuals (those scoring high on both the DAS
and BDI) recalled equal amounts of self-referent depressed and nondepressed content. This equivalence was predicted on the basis that the
BDI scores obtained by this group were within the mild to moderate
range of depression (their mean BDI score was 16.48). In sum, the recall
patterns obtained by these two groups offered a further replication of the
Kuiper and Derry (1982) findings for mild depressives and normals, as
represented in this study by vulnerable depressed and nonvulnerable
nondepressed individuals, respectively.
Of special interest in the Kuiper et al. (1985) study was the type of
self-referent content which might be recalled by vulnerable nondepressed individuals, or those scoring high on the DAS but low on the
BDI. It was found that these individuals did not display any evidence of
negative self-schema content. Instead, their pattern of findings was remarkably similar to normals (nonvulnerable nondepressed individuals). In terms of the recall measure, vulnerable nondepressed individuals recalled far more nondepressed than depressed content adjectives,
as had the normals. Similarly, a tally of the number of yes responses to
Depression and Self-Worth Contingencies
131
self-referent judgments revealed strong consistencies between nonvulnerable nondepressives and vulnerable nondepressives. Individuals in
both of these groups said yes to far fewer of the depressed adjectives than
individuals in the vulnerable depressed group.
Further evidence for a positive-content self-schema in vulnerable
nondepressed individuals was obtained in a study by Kuiper and Cole
(1983). Instead of self-referent trait judgments, participants in this study
provided estimates of the frequency, intensity, and duration of their
own prior depressive episodes. For the frequency and intensity measures, both the nonvulnerable nondepressed and vulnerable nondepressed groups gave significantly lower estimates than the currently
depressed group (vulnerable depressed). In other words, vulnerability
level per se did not lead to an increase in negative self-referent content.
It was only the actual presence of depressive symptomatology that produced an increment in these estimates. As such, this finding converges
on the notion that negative self-schema content is not evident in vulnerable nondepressed individuals.
Work with former depressives has also shown that a negative view of
self is not evident in the remission phase (Laxer, 1964; Wilkinson &
Blackburn, 1981). This conclusion was also reached in a study by Hammen, Miklowitz, and Dyck (1986). In this longitudinal study, individuals
completed the self-referent recall task twice, once when depressed and
later when nondepressed. Of particular interest was the finding that
recall for negative self-schema content decreased significantly when
the individual became nondepressed. This pattern is consistent with the
present self-worth model of depression, which proposes that negative
self-schema content is an episodic marker of depression.
Other findings offer further indirect support for this particular aspect
of the self-worth contingency model. Research by Eaves and Rush
(1984), for example, has shown that dysfunctional attitudes are still
evident during the remission phase of depression. In contrast, automatic
cognitions, which have a more pronounced negative self-referent focus
(i.e., "I can't do anything right"), were found to be evident only during
the depressed state. Similarily, two studies by Rholes et αϊ. (1985) found
that automatic cognitions cannot reliably predict future depressive episodes, whereas dysfunctional attitudes can. Taken together, these findings again converge on the notion that negative self-referent content is a
concomitant aspect of depression. Furthermore, these findings suggest
that an important distinction should be made between dysfunctional
cognitions that play an etiological role in depression, and those that are
evident only after the onset of this disorder (Beck & Epstein, 1982;
Kuiper & Olinger, 1986).
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Nicholas A. Kuiper and L. Joan Olinger
3. Self-Schema Consolidation
Although the self-worth model proposes that vulnerable nondepressed individuals have a positive view of self, it also suggests that this
self-schema is poorly consolidated. In particular, it is proposed that
vulnerable nondepressed individuals are frequently engaged in assessing their self-worth, as determined by the contingencies expressed in
their dysfunctional attitudes. As such, their positive view of self is subject to frequent réévaluation and interpretation, with the vulnerable
individual being overly concerned about whether this positive view is
warranted. This results in a poorly consolidated self-schema, in contrast
to the well-integrated self-schema exhibited by nonvulnerable nondepressives (see Table II).
As described in Section V, A,l, one manifestation of this poorly consolidated self-schema is the vulnerable individual's increased sensitivity
to attitude-relevant environmental information (Olinger et al., 1986a).
Along with a poorly consolidated self-schema, this increased sensitivity
may account for the enhanced emotional responsiveness exhibited by
individuals endorsing irrational beliefs (Vestre, 1984). Currently depressed individuals also report being more upset about stressful events
in their lives than nondepressed individuals, and indicate that these
events result in greater feelings of uncertainty (Hammen & Cochran,
1981). Overall, these ephemeral views of self seem to reflect the vulnerable individual's continuing struggle to maintain a positive sense of
self-worth.
A study in our own laboratory offers further evidence to indicate that
vulnerable nondepressed individuals exhibit a poorly consolidated
self-schema (MacDonald, Kuiper, & Olinger, 1985). In line with previous work (MacDonald & Kuiper, 1984), this study focused on the consistency aspect of self-schema consolidation. In the first part of the
study, mild depressives, normals, and vulnerable nondepressed individuals decided which adjectives, in pairs of nondepressed and depressed adjectives, described them the best. Following this, subjects
were asked to rate each adjective on a 9-point self-reference scale. Based
upon a comparison of these two types of self-referent decisions, a measure of decision consistency was computed. In accord with predictions
generated from a self-schema model, it was found that normals exhibited greater decision consistency than mild depressives. Interestingly,
the vulnerable nondepressed group exhibited the same degree of decision inconsistency as mild depressives. In terms of the self-worth model,
this reduced consistency supports the proposal that vulnerable nondepressed individuals have a poorly consolidated self-schema.
Depression and Self-Worth Contingencies
133
4. Self-Worth Contingencies and Successful Coping
It is possible that vulnerable nondepressed individuals might perceive an event as failing to meet the self-worth contingency components
of their dysfunctional attitudes. If this is the case, coping attempts are
likely to be instigated. The vulnerable nondepressed individual may
employ a wide variety of coping responses, including both problem-focused and emotion-focused strategies (Billings, Cronkite, & Moos, 1983;
Folkman & Lazarus, 1980). All of these coping strategies, however, are
directed at further attempts to provide the conditions which will allow
fulfillment of the dysfunctional contingencies for self-worth.
In his or her coping attempts, the vulnerable nondepressed individual
may be successful. Successful coping would be defined by the vulnerable individual as being able, once again, to fulfill dysfunctional contingencies for self-worth. It is recognized, of course, that this definition of
successful coping is completely idiosyncratic to the vulnerable individual's dysfunctional self-evaluation system. Within this system, however, such coping would be judged successful for two reasons. First, the
reinstatement of self-worth contingencies allows the vulnerable individual to resume a positive view of self-worth. As such, any depressive
symptomatology which had begun to emerge would be alleviated. Second, the reinstatement of self-worth contingencies allows the vulnerable individual to reduce coping efforts. As detailed below, these coping
efforts are a further source of stress for the vulnerable individual.
B. Etiological and Maintenance Issues
Alternatively, the vulnerable individual may be unsuccessful in his
or her coping attempts, and be unable to reintroduce the conditions that
would permit fulfillment of dysfunctional self-worth contingencies.
Unfortunately, this possibility may occur for two reasons. First, the very
nature of dysfunctional self-worth contingencies may mitigate against
the successful resolution of problematic life situations. By and large,
these contingencies specify unreasonable and rigid rules for determining self-worth. As described in detail below for the interpersonal realm,
these characteristics may ensure that vulnerable individuals have a
difficult time meeting their self-worth contingencies. Second, the act of
coping, by itself, introduces additional sources of stress for the vulnerable individual. These further sources of stress are also outlined below.
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Nicholas A. Kuiper and L. Joan Olinger
1. Self-Worth Contingencies and Assertion Difficulties
Considerable research has established the fact that currently depressed individuals exhibit deficits in social skills and assertion (Barbaree & Davis, 1984). Depressed persons may either fail to express an
opinion or viewpoint about a potential issue of conflict, or they may do
so in an ineffective and whining manner (Weissman & Paykel, 1974).
Furthermore, depressed individuals often report high levels of subjective discomfort when attempting to behave in an assertive manner
(Youngren & Lewinsohn, 1980).
Past literature clearly indicates a relationship between current depression level and assertion difficulties, and has often lead to the suggestion that such difficulties may contribute to the maintenance of
depressive episodes. Much less is known, however, about the assertion
skills of vulnerable nondepressed individuals, and how these skills may
relate to the etiology of depression. Accordingly, Olinger, Shaw, and
Kuiper (1986b) conducted a study in which individuals at varying levels
of vulnerability and depression completed both the Assertion Inventory
(Gambrill & Richey, 1975) and the Conflict Resolution Scale (McFall &
Lillesand, 1971).
Of particular interest in the Olinger et al. study was the large number
of conceptual similarities that exist between the cognitive patterns displayed by individuals with dysfunctional attitudes and those with assertion difficulties. Ludwig and Lazarus (1972) have postulated that
nonassertive persons are characterized by the cognitions of (1) the desire
to be liked by everyone, (2) perfectionism and self-criticism, (3) unrealistic expectations and excessive criticism of others, and (4) the labeling of
assertive behavior as inappropriate. Rich and Schroeder (1976) have
speculated that assertive behavior may be cognitively inhibited by the
nonassertive individual's excessive desire for approval. Thus, the cognitive similarities between dsyfunctional attitudes and nonassertiveness may involve excessive approval seeking and perfectionism. Attitudinally vulnerable persons may consider assertive behavior to be
inappropriate. In this respect, dysfunctional attitudes stress self-denial,
in that approval or happiness of others is more important than the
individual's own approval or happiness. Furthermore, differences in
opinion are viewed as indicators of dislike. Overall, then, these dysfunctional attitudes would certainly appear to oppose the assertive expression of one's thoughts, feelings, and rights.
Given these similarities, Olinger et al. (1986b) reasoned that the vulnerable individual's attempts to guide and evaluate social interactions
via dysfunctional attitudes would hamper the development a n d / o r use
of necessary assertion skills. When the needs and desires of the attitu-
Depression and Self-Worth Contingencies
135
dinally vulnerale person conflict with those of others, the vulnerable
person may experience a threat to self-esteem. To cope with this threat
or loss of approval from others, the vulnerable person may deny his/her
own desires. Thus, when a vulnerable person does behave assertively,
h e / s h e is likely to experience subjective discomfort. Furthermore, the
failure to resolve interpersonal conflicts assertively is likely to interfere
with the quality of ongoing interpersonal relationships. In particular,
nonassertiveness may yield relationships characterized by tension and
unresolved conflicts.
In general, the results obtained by Olinger et αϊ. (1986b) support the
hypothesized cooccurrence of nonassertiveness and attitudinal vulnerability for depression. Compared to nonvulnerable individuals, vulnerable individuals failed to use appropriate strategies for dealing with
interpersonal conflicts, and also experienced significantly greater subjective discomfort when behaving assertively. Of particular importance
was the finding that vulnerable nondepressed individuals displayed the
same assertion deficits that characterize currently depressed individuals (Weissman & Paykel, 1974; Youngren & Lewinsohn, 1980). These
deficits may reflect the effects of attempting to direct one's interpersonal
relationships via self-denying and passivity-enhancing dysfunctional
attitudes. As such, the assertion difficulties documented by Olinger et
αϊ. may contribute to both the etiology and maintenance of depressive
episodes. For vulnerable individuals, dysfunctional attitudes would
serve as cognitive mediators that disrupt interpersonal relationships,
both prior to and during depressive episodes.
2. Self-Worth Contingencies and Self-Focused Attention
In the self-worth model it is proposed that coping attempts which
focus on dysfunctional self-worth contingencies also increase the vulnerable individual's level of self-focused attention. Unfortunately, increases in self-focused attention have generally been found to produce
further negative consequences for the individual, many of which are
consistent with the various cognitive, affective, and behavioral components of depression (Ingram & Smith, 1984; Smith & Greenberg, 1981). In
the cognitive realm, for example, increases in self-focu à attention
often lead to self-criticism and perceptions of self-blame (Brockner,
1979; Duval & Wicklund, 1972). Self-focused attention has also been
found to heighten negative affect (Ingram & Smith, 1984) and social
interaction problems (Fenigstein, 1979). Coupled with a basic proclivity
for self-blame (Eaves & Rush, 1984), this self-focused attention serves to
enhance the stress level of the vulnerable individual. In particular, the
person would begin to focus on the notion that s h e / h e is generally
worthless, and solely to blame for her/his condition. This conclusion, in
Nicholas A. Kuiper and L. Joan Olinger
136
turn, exacerbates the appearance of further aspects of depressive symptomatology, including cognitive, affective, behavioral, and psysiological
components. The appearance of these symptoms would then contribute
to hampering further attempts at effective coping. As one example,
Doerfler and Richards (1983) studied coping responses in depressed
individuals. In line with the current approach, it was found that those
individuals who focused too much attention on their own behaviors did
not recover adequately from their depressive episodes.
3. The Downward Spiral of Depression
In trying to restore the conditions necessary for fulfilling their dysfunctional self-worth contingencies, mildly depressed vulnerable individuals may ultimately exhaust their coping repertoire. If these individuals are unable, over a period of time, to fulfill their attitudinal
contingencies, then positive aspects of their self-schema are preempted
entirely by negative self-referent material. Using this self-schema, personal and social information of relevance to the vulnerable depressed
individual is processed in a highly negative fashion. The emergence of
this consolidated negative self-schema, along with the coping stress
associated with failing to meet self-worth contingencies, contributes to
the development of further depressive symptomatology. These factors
then act in a reciprocal fashion to produce the downward spiral of
depression, which ultimately culminates in clinical depression. The
cyclic feedback nature of these symptoms (affective, cognitive, motivational, physiological, and behavioral) hampers recovery from depression. As one illustration, the individual's negative view of self, and
his/her perceived failure to meet self-esteem contingencies, leads to
self-rejection. This produces a negativistic, self-critical presentation
style that enhances the possibility that others will reject the vulnerable
depressed individual. In turn, this rejection from others makes it extremely difficult for the vulnerable individual to fulfill her/his dysfunctional self-esteem contingencies, thus maintaining a state of depression.
C. Remission and Treatment Issues
One fundamental assumption of the contingency model is that symptoms of depression will remit once vulnerable individuals are again able
to fulfill their dysfunctional self-worth contingencies. As illustrated
throughout this article, this may happen in a variety of ways. Thus,
vulnerable individuals may remain nondepressed, may experience
only mild symptoms of depression, or may become severely depressed,
Depression and Self-Worth Contingencies
137
depending upon the stage at which they are able to satisfy their selfworth contingencies.
A major difficulty for the vulnerable individual, however, is that this
remission phase may be short-lived. As described in Section IV, it may
be extremely difficult for the vulnerable individual to satisify his/her
dysfunctional self-worth contingencies. Thus, a constant cycling
through periods of depression and remission would be expected.
In order for the vulnerable individual to break this cycle, the selfworth contingency model suggests that interventions be directed
toward the modification or elimination of dysfunctional attitudes (Beck
et αϊ., 1979; Keller, 1983). Of particular importance would be therapeutic
approaches which focus on replacing dysfunctional self-worth contingencies with more adaptive cognitions and standards. As one example,
an individual might endorse the dysfunctional attitude "If others dislike
you, you cannot be happy" (DAS Item 32) or "If I do not do well all the
time, people will not respect me" (DAS Item 4). For such an individual,
cognitive therapy procedures might prove extremely effective. After
identifying and highlighting the dysfunctional nature of the client's
self-worth contingencies (e.g., everyone has to fully approve of me
before I can consider myself a good person), it may prove possible to
provide more realistic and adaptive standards for evaluating self-worth
(e.g., the universal approval of others is generally impossible, and thus I
should consider myself a good person, even if some people occassionally
disapprove of me). It should be cautioned, however, that while therapeutic techniques based on this approach have enjoyed some success,
several problems remain (Hollon & Kriss, 1984; Kuiper & MacDonald,
1983). One problem, for example, is that negative self-evaluations and
self-blame tendencies are extremely resistant to therapeutic change
(Eaves & Rush, 1984). Fortunately, several researchers have begun to
address this issue (Orth & Thebarge, 1984; Sober-Ain & Kidd, 1984), with
additional investigators providing more general information on the
benefits of a social cognition approach to cognitive therapy (Goldfried &
Robins, 1983; Hollon & Kriss, 1984; Kuiper & MacDonald, 1983).
Another aspect of intervention derived from the self-worth model
pertains to preventive approaches for individuals found to be vulnerable to depression. Here, the DAS may have considerable potential as an
easily administered self-report measure of cognitive vulnerability to
depression. As such, this instrument may prove valuable as an inexpensive and effective means of identifying a priori those individuals particularly susceptible to developing future depressions. Once such individuals have been identified, variants of cognitive therapy and
stress-innoculation training might be employed in a preventive fashion.
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Nicholas A. Kuiper and L. Joan Olinger
As one illustration, in Section IV we proposed that negative parenting
styles and values may contribute to the development of dysfunctional
attitudes in children. In line with this proposal, we found DAS scores
obtained from 26 pairs of mothers and daughters to be highly correlated
(r = .53]. Given this degree of mother-daughter consistency, it is possible to envision preventive therapies which focus on either the parent or
child, or both, in an attempt to limit the transmission of such dysfunctional values and attitudes from one generation to the next.
In addition to preventive approaches which focus primarily on the
cognitive components of the self-worth model, it is also possible to delineate preventive approaches with a more behavioral focus. In this
respect, we have completed two studies examining the coping skills of
vulnerable depressed, vulnerable nondepressed, and normal individuals (Kuiper et αϊ., 1986a); Olinger & Kuiper, 1986). In both of these
studies it was found that currently depressed individuals displayed
poorer coping techniques than normals. As one example, current depressives displayed higher levels of wishful thinking and self-blame
than normals. Of special interest, however, was the finding that vulnerable nondepressives also displayed some dysfunctional coping skills,
even though they were not currently depressed. In particular, vulnerable individuals displayed high levels of self-isolation, a coping technique which may actually hamper the successful resolution of stressful
events. In addition, a longitudinal analysis found that those vulnerable
individuals who went from a depressed to nondepressed state engaged
in more problem-focused coping strategies than those vulnerable individuals who remained depressed at both times of assessment. Taken
together, these findings suggest that coping skills and assertion-training
techniques may prove profitable for vulnerable individuals, even if they
are not currently depressed. The self-worth model would also suggest,
however, that such techniques would be most effective if they also
incorporated a cognitive component that more directly addressed dysfunctional self-worth contingencies.
VI. CONCLUDING COMMENTS
This article has documented some of our research concerning social
cognition aspects of depression. One of the first steps in this examination
was the elaboration of self-schema characteristics in currently depressed individuals. Across several of our studies, there is now sufficient empirical evidence to formulate a self-schema model of depression. This model considers both self-schema content and degree of
Depression and Self-Worth Contingencies
139
consolidation, and relates these components to severity of depressive
symptomatology.
Building on this self-schema model, the next phase of our research
program has considered etiological aspects of depression. In particular, a
self-worth contingency model of depression was introduced and then
theoretically elaborated. In addition to incorporating the self-schema
model of depression, this self-worth model acknowledges the interactive nature of depression etiology. In this model, negative events that
impinge on dysfunctional self-worth contingencies are proposed as
basic contributors to depression etiology. This model also outlines selfschema components for vulnerable and nonvulnerable individuals, and
indicates how these components change as a function of self-worth
contingencies. To date, this model has received some empirical support,
and further research certainly appears warranted.
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Hot Cognition and Psychotherapy
Process: An Information-Processing/
Ecological Approach
JEREMY D. SAFRAN
Clarke institute of Psychiatry and
University of Toronto
Toronto, Ontario, Canada M5T 1R8
LESLIE S. GREENBERG
Department of Counselling Psychology
University of British Columbia
Vancouver, British Columbia, Canada V6T 1H2
I. Introduction
II. The Cognitive-Behavioral Model: Assumptions about
Cognition, Emotion, and Behavior
III. The Contributions of Cognitive Psychology
A. Information-Processing versus Ecological
Perspectives in Cognitive Psychology
B. Recent Developments
IV. Integrative Theory
The Adaptive Role of Emotion in Human
Functioning
V. Emotion and Psychotherapy
A. Adaptive Affect as a Motivator of Change
B. Challenging Maladaptive Cognitions
C. Assessing Mood-Congruent or Hot Cognitions . . .
D. Restructuring Maladaptive Schemata
VI. Conclusions
References
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ADVANCES IN COGNITIVE-BEHAVIORAL RESEARCH
AND THERAPY, VOLUME 5
Copyright © 1986 by Academic Press, Inc.
All rights of reproduction in any form reserved.
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Jeremy D. Safran and Leslie S. Greenberg
I. INTRODUCTION
The central theme which orients this article is the recognition that
researchers and theorists in the psychotherapy field require an integrative perspective on cognition, emotion, and action to guide their thinking about the process of change in psychotherapy. In this article we will
discuss a number of considerations relevant to the construction of such
a model and briefly review alternative ways that theorists have chosen
to think about the relationships among these three aspects of human
functioning. Our objective will not be in any way to fully articulate a
comprehensive model of the relationships among cognition, affect, and
behavior, but rather to articulate a number of considerations relevant to
the construction of such a model, in the hope that this process will be an
impetus to the development of relevant theory and research in the
future. In the process we will be talking not only about different approaches to conceptualizing the relationships among emotion, cognition, and behavior, but also about different metatheoretical perspectives on human functioning. Our impression has been that, all too often
in the past, theorists have accepted certain theoretical assumptions
without regard to the particular metatheoretical perspectives from
which regard to the particular metatheoretical perspectives from which
these assumptions derive and without consideration of alternative metatheoretical perspectives.
A further aim of this article is to refine the cognitive-behavioral
conceptualization of emotion. After briefly discussing developments in
the cognitive-behavioral conceptualization of the relationships among
cognition, emotion, and behavior, we will explore the contributions that
cognitive psychology has to make to our understanding of the role of
emotional cognition or "hot cognition" in the psychotherapy process.
Two different cognitive metatheoretical perspectives are compared: the
information-processing metapsychology and the ecological metapsychology. This comparison is followed by a discussion of the value of
integrating these metatheoretical perspectives in order to obtain a more
comprehensive metatheoretical perspective of human functioning. We
then outline our integrative model of emotional processing (Greenberg
& Safran, 1984b, 1986) in which emotion, cognition, and action are all
viewed as interdependent aspects of a complex system which is involved in generating meaning. T h e role of emotion in psychotherapy is
discussed, and we conclude with the presentation of a number of different types of therapeutic interventions which emerge from this integrative perspective.
Hot Cognition and Psychotherapy Process
145
II. THE COGNITIVE-BEHAVIORAL MODEL: ASSUMPTIONS
ABOUT COGNITION, EMOTION, AND BEHAVIOR
The cognitive-behavioral model of emotion is sometimes represented in simplified form as the A-B-C sequence, originally articulated
by Ellis (1962). In this model, "A" refers to the activating event, "B"
refers to beliefs and corresponding internal dialogue, and "C" refers to
the emotional consequence. While this model captures the central role
accorded to cognitive mediating processes in cognitive-behavioral
theory it fails to represent a number of important theoretical refinements which have taken place in this model over the years.
Early cognitive-behavioral theory emphasized the causal role that
conscious cognitive processes play in the production of emotion and
behavior (Beck, 1976; Ellis, 1962; Mahoney, 1974). Important tasks in the
early years of cognitive-behavioral theorizing consisted of arguing for
the superiority of mediational over nonmediational approaches and for
the value of assuming that the relevant cognitive processes are conscious, rather than unconscious.
As the cognitive-behavioral tradition has developed, other theoretical issues have come to assume increasing importance. Bandura's (1978)
argument about the need for a reciprocal determinist perspective cogently demonstrated the shortcomings of viewing the relationships
among cognition, behavior, and environment in a unidirectional causal
fashion. More recently, Zajonc's (1980) provocative article in American
Psychologist has sparked a lively debate about whether or not it is
reasonable to assume that cognition precedes emotion (e.g., Greenberg
& Safran, 1984a,b; Lazarus, 1984; Mahoney, 1984; Rachman, 1984; Zajonc, 1984).
In addition, some cognitive-behavioral theorists have begun to argue
for the importance of expanding our definition of cognitive processes to
include both conscious and unconscious cognitive processes (e.g., Kendall & Bemis, 1984; Mahoney, 1980; Meichenbaum & Gilmore, 1984;
Safran & Greenberg, 1986). A somewhat related development has been
the criticism of those cognitive-behavioral approaches which tend to
equate cognition with logical, conceptual activity, and to ignore or underemphasize the role of perceptual activity in human functioning
(Greenberg & Safran, 1980, 1981). The tendency to adopt propositional
logic as the sine qua non of human cognition has in the past left cognitive
behaviorists open to criticism from those who assert that emotional
problems persist even when clients know that their thinking is illogical
or irrational (Rachman, 1983; Wölpe, 1978). As we will argue in Section
146
Jeremy D. Safran and Leslie S. Greenberg
ΙΠ,Α the exclusive identification of human recognition with propositional logic follows from the computer metaphor which has dominated
the field of experimental cognitive psychology. While this metaphor has
played a valuable and instrumental role in the development of cognitive
psychology, it is important not to overlook its limitations. In Section ΙΠ,Α
we will examine in greater detail some of the implications of the computer metaphor for our understanding of human functioning.
III. THE CONTRIBUTIONS OF COGNITIVE PSYCHOLOGY
Over the years a number of theorists and researchers have urged
cognitive-behavioral therapists to turn to the field of experimental
cognitive psychology for new insights (e.g., Arnkoff, 1980; Goldfried,
1979; Greenberg & Safran, 1980, 1981). What exactly does mainstream
experimental cognitive psychology have to teach us about the relationship between emotion, cognition, and action? Unfortunately, as we
have concluded elsewhere (Greenberg & Safran, 1984b, 1986; Safran &
Greenberg, 1982b), traditionally cognitive psychology has had little to
say about emotion. While the investigation of cognitive processes once
again became a legitimate field of inquiry with the publication of
Neisser's (1967) Cognitive Psychology, emotion was not until relatively
recently granted equal status as a domain acceptable for scientific investigation. Moreover, as theorists such as Turvey (1977) and Weimer
(1977) have argued, traditional cognitive psychology has had little to say
about the relationship between cognition and action. These omissions
seriously restrict the relevance of mainstream experimental cognitive
psychology to the clinician, since problems in living always involve the
interactions among cognition, emotion, and behavior. We are not the
first to raise these concerns about mainstream cognitive psychology.
Ulric Neisser, considered by many to be one of the fathers of cognitive
psychology, has raised similar questions about the direction in which
the field is heading. Neisser's (1976, 1980) criticisms focus upon the
lack of ecological validity of much of the research that takes place in
experimental cognitive psychology and on the tendency of experimental cognitive psychologists to study phenomena which are artifacts of
artifical laboratory situations instead of the real phenomena of interest.
While our current criticism is a more specific one (i.e., the failure of
mainstream cognitive psychology to deal with the role of emotional
processes and action in human functioning), this failure can be seen as a
specific case of the general failure to investigate psychological phenomena in a holistic, ecologically valid context. While many cognitive
behavior therapists are turning to experimental cognitive psychology
Hot Cognition and Psychotherapy Process
147
for answers, we believe that it is important at this point to be somewhat
circumspect and to ask ourselves what exactly does mainstream cognitive psychology have to offer us as clinicians.
A. Information-Processing versus Ecological Perspectives in
Cognitive Psychology
T h e failure of mainstream cognitive psychology to provide clinicians
with the type of answers they need about the relationships among cognition, emotion, and action has led us to raise some more general and
fundamental criticisms of mainstream cognitive psychology. As Neisser
(1980) has pointed out it is important to realize that there is not one
cognitive psychology. It is important to distinguish between different
metatheoretical perspectives in cognitive psychology. T h e predominant
metatheory underlying cognitive psychology can perhaps best be described as the information-processing metatheory. Perhaps the most
influential metaphor in this tradition has been that of people as computing machines. As Shaw and Bransford (1977) pointed out, the brain computer analogy inherent in the information-processing perspective
has many valuable features, but its shortcomings should not be overlooked. This analogy has helped to free many psychologists from the
excessive restrictions of radical behaviorism by providing modeling
techniques which allow us to make precise theoretical predictions
about unobservable processes. Nevertheless, there are many aspects of
human psychological functioning which are not adequately captured
by the b r a i n - c o m p u t e r analogy. It is always best to remember that, as
with any analogy, the b r a i n - c o m p u t e r analogy is an approximate one,
and that in reality there are various aspects of correspondence and
noncorrespondence between human beings and computers. Again, as
Shaw and Bransford (1977) point out, cognitive psychologists in pursuing the person-computer analogy
tend to forget that humans and animals are active, investigatory creatures driven by
definite intents through a complex, changing environment replete with meaning at a
variety of levels of analysis. Thus we feel no tinge of theoretical compunction in
blithely comparing such active, knowledge seeking beings with unconscious, static
machines that lack a wit of natural motivation. Unlike humans and animals, who
perceptually mine the world for information on a need to know basis, artificial systems can soak up information passively by being spoon-fed batches of alpha numeric
characters that have been conceptually predigested by human programmers. . . . In
such a sterile model of man, perceiving becomes a passive process and knowing a
purposeless one, and as for action (that is purposive behavior), it remains non-existent, (p. 3)
Not all cognitive psychologists, however, subscribe to an information-processing metatheory. Perhaps the most serious metatheoretical
148
Jeremy D. Safran and Leslie S. Greenberg
contender is the ecological metatheory initially advanced by J.}. Gibson
(1966). The ecological perspective focuses upon the interaction between
the person and the environment in which he or she lives. Human beings
are thus seen as organisms which live and operate in the context of
specific environments and are adapted through an evolutionary process
to their environmental niche. The ecological perspective is thus afunctional perspective. It is concerned with understanding the adaptive
significance of various aspects of human functioning in the context of
the environment in which they have evolved. It is thus assumed that
there is no way that we can begin to understand human psychological
functioning without a detailed understanding of the environment in
which this functioning takes place. The emphasis is thus much more
upon the interface between people and their environment than it is
upon information-transforming processes which are hypothesized to
take place inside the individual's head.
Consistent with this, the emphasis of the ecological perspective is on
the acquisition o/knowledge from the environment rather than upon the
processing of information about the environment. This may appear to be
a subtle distinction, but in fact it is a very real and fundamentally
important one. The information-processing perspective focuses upon
the processing of information which the organism is presumed to register passively. (However, note that different information-processing
theorists vary with respect to their assumptions about how active a role
the individual plays in the processing of information.) The ecological
perspective, however, does not make the types of distinctions that information-processing theory makes between different aspects of human
functioning, such as perception, action, and cognition. Since the individual is conceptualized as an organism in interaction with its environment and the emphasis is upon the acquisition of knowledge about the
environment, action is seen as part of the process of acquiring such
knowledge. The assumption is thus that one cannot understand cognition independent of action. The separation of human functioning into
action and cognition is thus an artificial one. Acting upon the world and
acquiring knowledge about the world are parts of the same process.
Since the ecological perspective focuses upon the interaction of the
organism with the environment and the assumption is that the organism
is adapted to its ecological niche, it is also assumed that perception is the
fundamental act through which the organism acquires information
about the environment. In the traditional information-processing perspective it is customary to focus upon perception in one sensory modality at a time. Thus, information-processing theory develops a model of
visual perception or a model of auditory perception. In contrast, the
ecological perspective emphasizes that perception takes place in all
Hot Cognition and Psychotherapy Process
149
sensory modalities simultaneously. Thus, in the most radical form of the
ecological approach (e.g., Gibson, 1966), it becomes unnecessary to
speak about higher level cognitive processes which transform information into a form where it can be used by the organism. T h e assumption is
that the organism becomes attuned to the environment so that the individual perceives meaning in the environment. T h e act of perception
thus assumes a central role in the ecological perspective and it is assumed that the focus of investigation should be at the point of interface
between the organism and the environment (i.e., perceptual activity)
rather than at some higher level cognitive information-processing activities which are hypothesized to be taking place. Perception is conceptualized as more than an initial step in a chain of information-processing
activity. It is hypothesized that meaning is inherent in the act of perception, and that knowledge of the world is acquired directly through simultaneous perceptual activity in all sensory domains.
From an ecological perspective it is thus seen as more parsimonious to
assume that evolution has rendered a complex process of information
processing unnecessary by designing perceptual systems which are
adapted to extract meaning directly from the environment. As Shaw
and Bransford (1977) state
Hence, when asked where the buck of knowledge ceases to be passed, or where the
epistemic regress ends, the ecological psychologist responds: At the beginning of the
process; it starts with perception, the process upon which the intrinsic meaning of
man's relationship to his world is founded. It is the perceiver who knows and the
knower who perceives, just as it is the world that is both perceived and known.
Neither memory, nor inference, nor any other epistemic process than perception
intervenes between the knowing agent and the world it knows, for knowing is a direct
rather than an indirect process, (p. 10)
A number of characteristics of the ecological perspective make it
more suitable than an information-processing perspective for helping us
to understand the role and nature of emotional processes in human
functioning. Emotion is a fundamental aspect of what it is to be human.
It is no less central to human functioning than are cognitions or behavior. A metatheoretical perspective based upon the person-computer
analogy alone will necessarily be inadequate for purposes of understanding and modeling the functioning of a living organism which is in
dynamic interaction with its environment, continuously acting, feeling,
and thinking.
Our position is that an approach to investigation which attempts to
understand the nature of cognitive processes by temporarily bracketing
off action and emotion is bound to come up with a distorted understanding of the phenomenon of interest. Cognition, emotion, and behavior are
in reality fused (cf. Greenberg & Safran, 1984b). T h e implications of this
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assertion extend beyond the commonly held cognitive-behavioral position that there is a reciprocally determining relationship among cognition, emotion, behavior, and environment. The notion of reciprocal
determinism, while conceptually useful, still assumes that each link in
the multidirectional causal chain possesses an independent existential
status. As Lazarus, Coyne, and Folkman (1982) have, however, aptly
stated,
Thoughts, emotions and motives are inferred from observations of the person, and we
have noted how they often have the same referents. How we partition these concepts
and punctuate theoretical sequences is often a matter of theoretical and methodological convenience. Yet we cannot lose sight of the fact that cognition, motivation and
emotion are inferential processes, not entities, each with a separate and independent
existence. For purposes of conceptual analysis, it is appropriate to distinguish among
them. However, we must realize that in nature, that is, in the actual phenomena of
human experience and action, they are usually fused and difficult to separate. To
speak of such fusion is not a matter of conceptual sloppiness but a recognition of the
necessity of putting the pieces back together into an organized whole, (p. 236)
For a number of reasons, then, we believe that mainstream cognitive
psychology has not and will not fully meet the high hopes and expectations that clinical psychologists have had for it. To summarize, the
adequacy of the information-processing tradition as a comprehensive
metatheory is compromised by (1) the failure to take into account the
fundamental role of motivation/emotion and perception in human
functioning, (2) the tendency to regard perception in an overly restrictive fashion, (3) the absence of a biological/evolutionary and ultimately
functional perspective, and (4) the failure to recognize that the practice
of modeling some aspects of human psychological functioning while
ignoring others provides a distorted picture of the phenomenon of interest.
In contrast to the information-processing approach, the ecological
perspective emphasizes the role of biological/evolutionary factors in
human functioning. In this respect it incorporates the type of neo-Darwinian perspective which has proved to be a powerful conceptual tool
in contemporary ethology (Bowlby, 1969; Lorenz, 1973). As Dixon (1981)
pointed out, a biological frame of reference can provide a much needed
corrective influence to cognitive theory and research. Moreover, the
ecological perspective eliminates the gap between epistemic processes
and actions which has plagued theorists in social and cognitive psychology (Baron, 1980). This is particularly important in the context of psychotherapy, where the ability to understand the relationship between
cognitive change and action in the world is paramount. Finally, the
ecological perspective provides a congenial framework for accommodating the type of affective-motivational considerations which are so
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central to psychotherapy. This is not to say that ecological theorists have
dealt extensively with such considerations in the past; they haven't. As
we shall see, however, the ecological emphasis upon inwired perceptual
adaptation and the complete interdependence between knowledge and
action provides a useful framework for this purpose.
While we have been quite vehement in our criticisms of the mainstream information-processing approach it is important not to "throw
out the baby with the bathwater." We believe that while informationprocessing metatheory has the above limitations, it also has some valuable features. Neisser's (1976) book Cognition and Reality provides an
excellent example of a compromise position which attempts to combine
the best features of an ecological perspective with the best features of an
information-processing perspective. In this book Neisser adopts the ecological emphasis upon perceptual processing and interaction with the
environment but also retains the information-processing concept of
schema. He proposes that the individual acts upon the world through
perceptual activity and that this activity revises expectations or schemata in an ongoing fashion. The individual acts upon the environment
and is in turn acted upon by the environment. This ongoing modification of his or her expectations in turn continues to direct perceptual
activity in an ongoing fashion.
Our objective is to advocate a middle ground position, similar in some
respects to that described above. Epistemologically the position we hold
is best described by what Bhaskar (1979) has termed transcendental
realism. This is a falliblist realism in which knowledge is viewed as a
social constructive process. At the same time, however, it is acknowledged that there is a real world that exists independent of cognizing
experience. This results in a view of the cognitive system as constructive but as being able to be more or less accurate and to be continually
striving toward greater fidelity of representation of what actually exists
independent of the constructive process. In Section ΙΠ,Β we will discuss
some of the developments in information-processing theory which we
believe can be usefully incorporated into this middle ground position.
B. Recent Developments
There are a number of recent theoretical and empirical developments
in the field of cognitive information-processing theory that we believe
are useful for purposes of incorporating emotion into a more integrative
view of human functioning and psychotherapy. Three such developments we will discuss are research and theory on unconscious information processing, associative network models, and schema models.
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1. Unconscious Information Processing
One important development in the field of cognitive information processing that we believe is particularly relevant to the understanding of
emotional processes in human functioning is the research and theory on
unconscious information processing (Greenberg & Safran, 1986; Safran
& Greenberg, 1986). It is interesting to note that those theories of psychological functioning which were initially developed to account for a variety of clinical phenomena (e.g., Freud, 1 8 9 6 / 1 9 6 3 ; Janet, 1 9 0 7 / 1 9 6 5 )
relied heavily upon the notion of unconscious motivation, and the
influence on behavior of information processing that occurs outside
of conscious awareness. As Bowers and Meichenbaum (1984)
point out it is no surprise that theories developed initially to account for
complex clinical phenomena relied upon formulations of the unconscious, given the apparent incomprehensibility of much "abnormal behavior" when viewed from a rational perspective. With the ascendance
of the behavioral tradition in experimental psychology, theories dealing
with unconscious processing fell into disrepute as did all mediational
theories. When consciousness once again became a legitimate domain of
inquiry, it is not surprising that one of the last areas of investigation to
gain legitimate status was the domain of the unconscious. Given the fact
that unconscious processes by their very definition seem to be nonamenable to direct observation and thus empirical investigation, unconscious processing was one of the last domains to gain legitimacy as a field
for investigation. However, as recent theorists and researchers have
begun to recognize, it is impossible to have a viable theory of conscious
information processing without having a theory of unconscious information processing (Bowers & Meichenbaum, 1984: Dixon, 1981;Shevrin
& Dickman, 1980; Mahoney, 1980). One of the first areas of investigation
in cognitive psychology to open the doors to the investigation in cognitive psychology to open the doors to the investigation of unconscious
information processing was research on selective attention (e.g., Broadbent, 1958; Kahneman, 1973; Neisser, 1967; Treisman, 1969). Other active areas of relevant research have been the work on subliminal perception (e.g., Dixon, 1981) and on implicit learning (e.g., Reber & Lewis,
1977). We have reviewed this literature and discussed the importance of
unconscious processing elsewhere (Greenberg & Safran, 1986; Safran &
Greenberg, 1986) and will limit ourselves here to noting the increasing
recognition in cognitive psychology of the importance of unconscious
processing in influencing people's perceptions and actions.
2. Associative Network Models
Another major theoretical and research development in the field of
cognitive information processing which we find to be particularly relevant for purposes of understanding the nature of emotional processes in
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psychotherapy is the concept of semantic networks. As Johnson-Laird,
Herrmann, and Chaffin (1984) point out, semantic network theories are
essentially an evolution of a basic associationist model resulting from an
attempt to frame such models for computers. There is nothing new
about the assumption that words and concepts vary with respect to the
degree of associative relationship they have with one another. What
distinguishes semantic network theory from simple associative
theories, however, is the ability of semantic network theory to go
beyond a simple model of word association to one of meaning. The
inadequacy of a simple associationist model for purposes of understanding memory for meaning is illustrated by the following example taken
from Johnson-Laird et αϊ. (1984). The word black is strongly associated
with both white and night. However, the nature of the relationship
between black and white is very different from the nature of the relationship between black and night. An adequate model of meaning
therefore requires the ability to distinguish between different kinds of
concepts and different kinds of links between concepts. The development of computer modeling techniques provided theorists with the
conceptual tools for labeling different kinds of concepts and different
kinds of links between concepts. In semantic network models the relationship between different items stored in memory is represented in
terms of the degree of association between items in the network (represented by the length of the link or pathway), the nature of the association (represented by the label of the link), and the nature of the items
which are associated (represented by the labels attached to nodes in the
network). A number of different semantic network theories have been
developed (e.g., Anderson & Bower, 1973; Collins & Loftus, 1975; Quillian, 1968; Rumelhart, Lindsay, & Norman, 1972).
These different network theories share a number of assumptions and
are different with respect to certain assumptions. A common feature of
all semantic network models, however, is that they provide a model of
the organization of information in memory which takes into account
that there are different kinds of information stored in memory and
different kinds of associations between information stored in memory.
All semantic network theories are able to make predictions about the
speed with which the activation of one element in a semantic network
should activate elements in the network, and the notion of spreading
activation of semantic networks is central to all semantic network
theories.
Bower (1981) has now extended the semantic network notion in order
to take into account the relationship between emotion and various other
aspects of meaning in memory. In Bower's model emotions are represented as specific nodes or units in memory that collect together many
different aspects of the emotion. Emotions thus play an important orga-
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nizational role in memory. T h e aspects which collect around emotion
nodes include autonomic reactions, standard roles and expressive behaviors, and descriptions of standard evocative situations which lead to
the particular emotion. According to Bower, each emotion node is also
linked with propositions describing events from one's life during which
the emotion was aroused.
These emotion nodes can be activated through the activation of any of
the units in memory which are linked to the emotion node. For example, the activation of a specific episodic memory associated with a specific emotion can activate that emotion. Similarly, the activation of a
particular expressive behavior linked to a specific emotion node can
activate that emotion. T h e activation of any one particular unit in memory which is linked to a specific emotion node may not necessarily
activate that specific emotion node, but may raise the threshold of that
particular node, so that it will be more easily activated by another unit
in memory which is linked to that emotion node.
3. Schema Models
Although the schema concept can be traced as far back as Bartlett
(1932), it has more recently acquired a new prominence in cognitive
psychology. While specific definitions of the schema construct vary
from theorist to theorist, in general there is agreement that schemata
can be thought of as cognitive structures in memory which organize
information abstracted from prior experience and which guide both the
processing of new information and the retrieval of stored information.
As evidence continues to accumulate about the central role of unconscious processing in human functioning, many researchers are turning
to the concept of schematic processing in an attempt to clarify the fashion in which the automatic encoding of fundamental information takes
place (Hasher & Zacks, 1984).
As Fiske and Linville (1980) argue, the schema construct, while not
without its problems, nevertheless appears to have some theoretical
merit when evaluated against specific criteria of good scientific theory.
Research has demonstrated that the schema construct does have some
predictive utility, has been profitable in terms of generating productive
research, and appears to have generalizability to a large number of
domains of interest (e.g., memory, attention, social psychology, and
clinical psychology). As we see it the issue of generalizability is an
important one since many of the constructs in cognitive psychology may
be formulated at a level of analysis that is appropriate to the intensive
investigation of specific processes at a molecular level of interest to
cognitive psychologists, but may not be sufficiently molar to constitute
an appropriate level for analysis for social and clinical psychologists.
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Leventhal (1984) employed the schema construct as a way of understanding the relationship between emotion and other cognitive processes. He hypothesized that emotional experiences are included in
memory in schematic structures consisting of a number of constituent
components, which combine as a whole to create the experience of
emotion. These constituent schematic elements include episodic memories for specific events associated with a specific emotional experience,
autonomic patterns associated with these experiences of specific emotions, images and expressive motor behaviors associated with specific
emotions. Leventhal (1982) theorizes that these schematic structures
are coded in memory at a preattentive level. According to him, when
one component of a specific emotion schema is activated, it increases
the potential for activating the entire schematic structure, resulting in
the subjective experience of the emotion associated with that schematic
structure.
This notion of schematic structures associated with emotions is very
compatible with Lang's (1983) theorizing about the role of emotion prototypes. According to Lang, emotion prototypes are structures in memory which are quite similiar to the type of structures about which Leventhal wrote, and which consist of similar constituent elements. Lang
also agrees that the activation of one element of an emotion prototype, or
the right combination of critical elements, will activate the entire prototype and result in the subjective experience of the associated emotion.
IV. INTEGRATIVE THEORY
It appears that schema and associative network constructs have a
number of similarities. Specifically, they both specify that different
events or features associated either temporally, semantically, or conceptually are linked in memory in one fashion or another. Furthermore,
both constructs stipulate that information can be coded and linked in
memory at a preattentive level, out of awareness. Finally, they both
stipulate that the activation of one unit in memory can lead to the
activation of associated units in memory, and that this activation can all
take place at the preattentive or unconscious level.
There are undoubtedly specific differences in terms of the predictions
that can be derived from schema theory and associative network theory,
and it will be important in the future to specify exactly what are the
similarities and differences in predictions. It may be the case that both
concepts are required in order to adequately describe and explain the
phenomena of interest. It may be, for example, that schema theory is
useful for talking about the domain of processing external information,
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whereas associative network theory is more useful for making specific
predictions about the processing of internal information. While these
types of issues remain to be clarified, it nevertheless appears that the
notions of schema, associative network, and unconscious or preattentive
processing may be of some theoretical utility.
Bearing in mind these developments in information-processing
theory, as well as the metatheoretical concerns discussed in Section
III, A, we will not outline some of the basic themes in our thinking about
the relationships among emotion, cognition, and action. Our intention
here is not so much to outline a comprehensive, integrative model of
emotional processing, as it is to outline theoretical guidelines which we
believe are useful in guiding our thinking about the relationships among
emotion, cognition, and behavior in the therapeutic context.
The Adaptive Role of Emotion in Human Functioning
We take as a basic starting point the assumption that emotion plays an
adaptive role in human functioning. This postulate can be accommodated within the ecological metatheoretical perspective, and has dramatic implications for our thinking about the relationships among emotion, cognition, and action in the psychotherapy process. It is thus truly a
basic epistemological assumption which shapes the very way in which
we think about the phenomenon of interest. We also believe that this is a
necessary assumption to allow us to think productively about affective
phenomena in therapy in all their complexity (Greenberg & Safran,
1984b, 1986; Safran & Greenberg, 1982a,b).
Along with other theorists (e.g., Arnold, 1960; Izard, 1977; Leventhal,
1982; Tomkins, 1980; Plutchik, 1980) we postulate that emotional processing has evolved in the human species through a process of natural
selection. Emotional processes thus play an adaptive role in human
functioning. This is not to say that a specific emotion is necessarily
adaptive in a specific context, but rather that, in general, emotional
processes play an adaptive role in human functioning.
In what way do emotions play an adaptive role in human functioning?
We hypothesize that emotions provide us with information about ourselves as organisms in interaction with the environment. Emotions
function to motivate adaptive action in the world. In the words of Michotte (1950), emotions are functional connections between the individual and the environment. They thus constitute a bridge through which
people are linked to their ecological niche. This bridge has evolved
through a process of natural selection. Emotions are not epiphenomena
or exclusively the product of the cognitive interpretation of nonspecific
arousal, as Schachter and Singer (1962) theorize. The basic structure for
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emotions is hardwired into the human animal (e.g., Izard, 1977; Leventhal, 1982; Tomkins, 1980).
Emotions function as action dispositions. Different classes of action
are inherent in different emotions. Anger, for example, will lead to
aggressive, self-protective behavior if carried through into action. Fear
will lead to self-protective behavior through flight if carried forward
into action. Loneliness can lead to affiliative action. Affiliative behaviors play a strong role in terms of the survival of the species. Love can
lead to affiliation and to procreation.
1. Emotion and Nonverbal Behavior
It is commonly observed that there appears to be some kind of integral
relationship between emotion and nonverbal behavior. This of course
has tremendously important implications for the practice of psychotherapy. We essentially "read" other people or infer what is going on for
them intrapsychically on the basis of nonverbal cues (Kiesler, 1982).
Elsewhere (Greenberg & Safran, 1986) we have reviewed the growing
body of evidence demonstrating that there are both cross-individual
and cross-cultural similarities in terms of the specific nonverbal behaviors and configurations of nonverbal behavior which are associated with
specific emotions. Research of this type has been seen by some (e.g.,
Izard, 1977; Tomkins, 1980) as corroborating the hypothesis that the
basic structure for specific emotions is hardwired into the human species.
Moreover, since the majority if not all of this research has focused on
the relationship between facial expression and emotion, some theorists
have concluded that facial feedback a n d / o r facial feedforward plays a
central role in the production of emotional experience (e.g., Izard, 1977;
Leventhal, 1982; Tomkins, 1980). We hypothesize that the relationship
between emotion and nonverbal behavior is not necessarily restricted to
the facial region. However, we believe that the relative ease with which
the relationship between emotions and facial expression can be detected is accounted for by the fact that facial expression plays a significant role in nonverbal communication. We thus hypothesize that facial
expression has evolved into the most visible, nonverbal marker of emotional change, but that it is not necessarily the only anatomical cue
pattern in which nonverbal specificity is associated with emotional
change (Greenberg & Safran, 1986).
As stated previously, different emotions appear to have different action tendencies inherent in them. Emotions are thus not purely a subjective experience. They are inherently behavioral in nature. The experience of fear, for example, consists of nonverbal behavior as well as a
subjective experience (Lang, 1983). These nonverbal behaviors may
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consist of specific and recognizable facial expressions as well as particular patterns of muscular movement or tension in the upper or lower
torso. Muscular tension in the upper and lower torso can potentially
lead to fight or flight behavior if further elaborated. These nonverbal
behaviors are thus part of an action disposition. If actualized they will
lead to more extensive actions in the world which are either directly
instrumental in nature or have a communicative function. They are
thus a biological link to the ecological niche.
2. Emotion and Perceptual - Motor Processing
As Turvey (1977) argues, there is an integral link between perception,
action, and knowledge of the world. We argue further that there is an
integral link between perception, action, knowledge of the world, and
knowledge of the self. This fourth dimension, i.e., knowledge of self, is
brought into play through the cognitive representation of our own expressive/motor experience. There is something fundamental and basic
about the perceptual motor system. As Piaget (1954) pointed out, a
child's initial response to the world is perceptual-motor in nature. In
acquiring knowledge of the world a child constructs sensory motor
schemata long before he or she can construct more abstract representations of the world. These sensory motor schemata are essentially representations of the child's actions upon the world. A child thus comes to
know the world initially through a combination of his or her perception
of objects in the world and through his or her manipulation of these
objects. As ecological theorists point out (Gibson, 1979), perception and
action are thus integrally related. Acquiring knowledge of the world
through our actions upon it does not occur only in infants. As Polanyi
(1966) argues, action upon the world lies at the heart of knowledge
acquisition. Adults are able to operate upon the world through complex,
abstract symbolic processes, but these abstract processes always remain
ultimately tied to action and perception.
3. Emotions and Meaning
Gibson's (1979) concept of affordances is useful here for clarifying the
relationships among emotion, perception, and meaning. According to
Gibson (1979), objects in the world have an inherent meaning for human
beings and this meaning is grasped in terms of what the objects afford to
the person or what their functional value is. A flat surface affords a
surface for walking. A small, hard object affords a potential missile for
throwing. We thus perceive (and it is important to remember that for
Gibson perceiving and knowing are synonymous) objects and events in
terms of their affordances. The addition of emotions to Gibson's ecological analysis adds another dimension to the equation. Not only do we
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know obj ects in terms of what they afford us, but also in terms of the way
in which they impact upon us as biological organisms. This latter information is gleaned through the action tendencies that different objects
pull from us. As ecologically oriented theorists maintain, meaning is
inherent in the act of perception. This meaning emerges out of perceiving not only objects and events, but also the implications of these objects
and events for us as biological organisms. The meaning of an object or
event for us as biological organisms is essentially the action disposition
which it evokes in us. And this in turn is the root of emotional experience.
4. The Emotional Synthesis Process
Emotion theorists, who are oriented by a biological/evolutionary
perspective, provide us with a view on some of the possible primary
emotions and their functions. Izard (1977), for example, recognizes the
existence of ten fundamental emotions: interest, joy, surprise, distress,
anger, disgust, contempt, fear, shame, and guilt. Other theorists such as
Tomkins (1980) and Plutchik (1980) have their own overlapping variations.
Although there is some disagreement among theorists as to what
emotions are primary and what emotions are more complex derivations
of these primary emotions, there is agreement among all theorists assuming a biological/evolutionary perspective on emotion that the
structure for certain primary core emotions is wired into the human
organism. Again, consistent with theorists such as Arnold (1960) and
Leventhal (1979, 1982), we hypothesize that the neurological substrate
for emotional experience which is wired in includes a code for specific
configurations of expressive motor behavior which correspond to specific primary emotions. We are in no sense, however, claiming that
emotional experience in the adult human being is in any sense restricted to these simple, primary emotions and associated expressive
motor configurations.
How is it that the basic neurological template for emotional experience becomes elaborated in the human being into the infinitely subtle
blends of emotional experience that are characteristic of human functioning? How is it that expressive motor behaviors or action dispositions
become integrated with perceptual activity and higher level abstract,
conceptual processing to produce the subtle, complex cognitiveaffective experiences which we have? It is at this point that the information-processing concepts discussed in the previous section can be
useful. We hypothesize that, as Leventhal ( 1 9 7 9 , 1 9 8 2 , 1 9 8 4 ) suggests, a
type of unconscious information-processing activity takes place which
synthesizes information generated through perception of the environ-
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ment, neural impulses associated with expressive motor behaviors, and
higher level conceptual processing.
The human organism responds to the environment in an immediate,
reflexive fashion. A moment's reflection will confirm for the reader that
action in the world is often an automatic rather than a deliberate process. One perceives and acts in the same moment. One does not stop to
think about putting one foot in front of the other before this takes place.
Instead, perception and action are integrated perceptual-motor activities which occur simultaneously. We hypothesize that this process is the
same in the realm of emotional experience. One engages in an immediate perceptual-motor appraisal of environmental events, which becomes synthesized into subjective emotional experience. This perceptual motor appraisal [or what Arnold (1960) refers to as the primary
appraisal] does not depend upon a prior stage of conceptual appraisal. At
the same time that it is taking place, however, the primary appraisal is
being conceptually appraised. This conceptual appraisal is referred to
by Arnold (1960) as the secondary appraisal. Thus, a complex, multidirectional type of information-processing activity at an unconscious
level is constantly taking place. This activity integrates information
generated both from inside and outside of the organism, and results in
the conscious experience of emotion. In addition to generating emotional experience on a moment-to-moment basis, the information generated by this synthetic process becomes stored in memory. Thus, from
the moment of birth, a child accumulates memory stores consisting of
episodic memories and images of eliciting environmental events,
evoked expressive motor responses, associated autonomic arousal, and
associated conceptual appraisal.
These memories become progressively elaborated and refined over
time and are central to emotional experience. The memory structures
can be conceptualized either as schema-type structures (Lang, 1983;
Leventhal, 1979, 1982) or as semantic networks (Bower, 1981). As previously discussed the specific differences in predictions that these theoretical constructs make will need to be tested before decisions can be
made as to which is the more useful of the two concepts. The common
theme to both of these concepts, however, is that emotional experience
becomes coded in memory structures which incorporate a number of
subsidiary components. When an individual either attends to information or generates information internally which matches one of the subsidiary components, the probability of other associated components becoming activated increases. As Fiske and Linville (1980) suggest, the
theoretical and empirical refinement of schema theory will depend on
our ability to find the answers to questions such as "When are schemata
retrieved as a whole and when are they partially retrieved?," "Are
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exceptions stored within schemata?," and "To what extent do people
unpack their schemata into component parts?"
Without the answers to these questions, however, we can still hypothesize that the information generated by the activation of a
cognitive-affective schema or a semantic-emotion network is integrated at a preattentive level with the perception of the eliciting stimulus and with the conceptual appraisal of both external and internal
information. The integration of information from all of these sources
results in the conscious experience of emotion. In this fashion, emotions, cognition, and action are fused through a type of preattentive
information-processing activity which is constantly combining information from both external and internal sources. Emotional experience
is thus in no way restricted to the simple, basic categories which constitute the underlying substrate for emotional experience. Complex and
subtle blends or derivatives of the more basic emotion substructures are
established through the development of the complex cognitiveaffective structures in memory which store the individual's unique
experiences in life, and his or her idiosyncratic responses to them.
Some of the major themes we have discussed so far can be summarized as follows:
1. Emotion, cognition, and behavior are fused.
2. The cognitive-affective system is adapted to the ecological niche.
3. Emotion has an adaptive function.
4. Emotional experience involves the synthesis of information from
sources both external and internal to the organism.
5. The conscious experience of emotion is thus the product of a preattentive synthesis of subsidiary components.
6. Emotional experience tells us what events mean to us as biological
organisms.
7. Emotion is a form of tacit meaning.
V. EMOTION AND PSYCHOTHERAPY
Our perspective on emotion can be thought of as a compromise between an information-processing and an ecological perspective. We believe that a number of assumptions more consistent with an ecological
than an information-processing metatheory are necessary if we wish to
understand clearly the relationships among cognition, emotion, and
action. These include the recognition that (1) expressive motor responses are biologically inwired action tendencies, (2) the organism is
adapted to its ecological niche, (3) perception and action are interdepen-
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dent, and (4) meaning is inherent in emotion and in the process of
perception. Certain concepts derived from the information-processing
metatheory are, however, also useful for purposes of fully understanding the relationships among emotion, cognition, and action. In particular, the information-processing tradition provides us with theoretical
concepts which are useful in understanding the way in which emotional experience is synthesized from various subsidiary components,
stored in memory, and activated under certain conditions.
The type of cognitive-affective system we have postulated, in which
primary emotion prototypes interact with higher level cortical processes, has some distinct advantages from an evolutionary perspective.
While the wired-in nature of the emotional system allows the opportunity for immediate, adaptive, reflexive responses to environmental
events, there is not an inflexible link between environment and behavior. T h e conceptual aspect of the emotional synthesis process creates a
break in the environment-behavior chain. The emotional synthesis
process thus generates action disposition
information
which is subjected to further processing, and which can ultimately lead to action.
As we have argued previously (Greenberg & Safran, 1984b, 1986), a
theoretical understanding of the relationships among emotion, cognition, and action can be extremely useful for purposes of understanding
the development of emotional problems as well as clarifying our understanding of the process of change in psychotherapy. An understanding
of the function of emotion and the way in which the cognitive - affective
system functions under optimal conditions provides us with clues as to
the way in which this system can break down when people have emotional problems. It can also provide us with clues as to how to restore the
organism to healthy functioning.
A. Adaptive Affect as a Motivator of Change
If we begin to think of emotion from the vantage point that we have
outlined, it becomes apparent that any theory of human change which
overlooks the adaptive role of emotion in human functioning cannot be
fully adequate. We thus believe that the refinement of cognitivebehavioral theory in a fashion which incorporates this perspective will
have important theoretical and practical benefits.
Moreover, the importance of articulating a systematic theory of emotion which incorporates this functional perspective extends beyond the
refinement of cognitive-behavioral theory. As Greenberg and Safran
(1986) have argued, traditionally psychoanalytic theory has never really
had an adequate, systematic, general theory of emotion. And, while
experientially oriented therapists such as Rogers (1951) and Perls (1973)
have had a perspective on the adaptive role of emotion in human func-
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tioning, their view has not been embedded in the context of a systematic
theory about the relationships among cognition, affect, and behavior.
Moreover, many practitioners of experientially oriented therapies are
guilty of advocating that clients "fully experience their emotions"
without having a framework for discriminating when this should occur
nor a systematic rationale as to how this is therapeutic. The variety of
human potential and therapeutic encounter movements which proliferated during the 1960s and 1970s unfortunately contributed to the misconception that the full experiencing and expression of emotion is an
end unto itself, regardless of the client's specific situation and state.
This has increased the confusion as to the extact function of the
experience and expression of emotions in psychotherapy.
A central tenet of the perspective outlined above is that primary
emotions generate important information about the meaning of events
for us as biological organisms and motivate behavior in a potentially
adaptive fashion. It is important to recognize that affect is information.
As Leventhal (1982) maintains, emotions play a role in providing us with
information about the readiness of our biological machinery to interact
with specific events in the environment, and in integrating abstract
cortical functions with perceptual motor reflexes, so that we can sense,
think, act, and feel in an integrated fashion. Emotions "can be regarded
as a form of meaning. They have significance for the person experiencing and expressing them. Their meaning has two aspects: they 'say'
something about our organismic state (i.e., they meter its moment-tomoment readiness) and they 'say' something about the environment"
(Leventhal, 1982, p. 122).
It follows that individuals who, for whatever reasons, are not able to
fully use or do not have complete access to this information will function in a less than optimal fashion. Consistent with this, a common
clinical problem, in our observation, occurs when clients fail to fully
synthesize certain adaptive emotional experiences. Because of past experiences they may learn that it is inappropriate or dangerous to have
certain types of emotional experiences, and as a result may restrict the
expression of certain emotions or may even fail to completely synthesize certain types of emotions. We hypothesize that both intensity and
degree of redundancy of specific classes of learning conditions play roles
in determining to what extent an individual will have difficulty in
synthesizing associated emotions. In more extreme maladaptive learning situations the individual may fail to develop in memory any elaborated representations of the relevant emotions and thus actually have
difficulty in completely synthesizing the relevant emotional experience. When the maladaptive learning is less extreme, the individual
may be able to partially synthesize the relevant emotion, but may have
difficulty in fully experiencing and expressing it. Common areas of
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Jeremy D. Safran and Leslie S. Greenberg
emotional deficit are inability to synthesize experiences of weakness or
vulnerability, and experiences of anger (Greenberg & Safran, 1986; Safran and Greenberg, 1982a). Deficits in emotional processing are, however, by no means restricted to these areas.
A brief clinical illustration may help provide an example of the type of
deficit in emotional synthesis about which we are speaking. A 32-yearold woman was admitted for treatment. She had a 5-year history of
depression and a diagnosis of major depressive disorder with melancholia. The most distinctive feature of her clinical picture was her complete
anhedonia and the nonreactivity of her mood state to any environmental events. This lack of emotional reactivity was one of the major clinical
features leading to the diagnosis of an endogenous depression. Over the
5-year period, she had been treated with a host of psychotropic medications, both conventional and experimental, without result.
She was finally placed on a trial of cognitive therapy in an attempt to
help her. In therapy it emerged that her lack of emotional reactivity was
very closely linked with tacit rules or dysfunctional beliefs she had
about the importance of always being in control of her feelings, and the
potential dangerousness of expressing or even experiencing feelings of
anger, love, and vulnerability. It is important to emphasize here that the
emotional deficit was not restricted to the realm of expression. According to her retrospective report, prior to the commencement of therapy
she literally did not experience these emotions. Failure to adequately
synthesize and express these emotions helped to keep her trapped in an
unsatisfactory life situation wherein she was not getting many of her
basic needs for love, support, and gratification met either in her marital
relationship or in any of the other major social relationships in her life.
Therapy with this woman consisted of helping her to gradually learn to
synthesize the constricted emotions. There were two major components
of the invervention: (l)modifying her cognitions concerning emotion,
and (2) bringing automatic expressive motor-schematic processing into
awareness.
The first component consisted of helping her become aware of her
tendency to become self-critical whenever she began to experience
emotion and to abstract and gradually challenge the underlying dysfunctional attitudes which guided this self-critical activity. Examples of
such dysfunctional attitudes were "I must always be in control of my
feelings in order to be a worthwhile person; I must always be strong in
order to be worthwhile"; and, "A strong person never expresses feelings
of anger or weakness." Further exploration revealed fears that she
would be rejected if she ever expressed either weakness or anger. We
view this type of intervention, in which dysfunctional attitudes about
the experience and expression of emotions are brought to awareness
and challenged, to be similar to gestalt therapy methods of becoming
Hot Cognition and Psychotherapy Process
165
aware of and identifying with or taking responsibility for resistances
(Perls, 1973). These methods originate in turn from Reich's (1949) notion
of interpretation of resistances and defenses, which is an intervention
advocated by many current psychodynamic theorists (e.g., Horowitz,
Marmar, Krupnick, Wilner, Kaltreider, & Wallerstein, 1984; Schafer,
1983). It is important to note that in advocating an intervention similar
in some ways to the interpretation of defenses, we are in no way endorsing the drive metapsychology of psychoanalysis (see Safran & Greenberg, 1986, for a more detailed discussion of this point.)
This emphasis on exploring and challenging self-critical activity and
dysfunctional attitudes regarding certain kinds of emotional experience
is not completely inconsistent technically with the practice of cognitive
therapy (Beck Rush, Shaw & Emery, 1979). Important differences, however, are the nature of the cognitive activity which is targeted for intervention, as well as important metapsychological assumptions about the
fundamental nature of emotion. From a conceptual perspective, the
important addition to cognitive therapy suggested here is that emotions
play a potentially adaptive role in human functioning, and that emotional problems can result from a failure to synthesize adaptive emotions. This failure results, at least in part, from a blocking of the integrative process at the conceptual level. It is this cognitive activity blocking
emotional synthesis that often requires modification.
In addition to modifying the processing of affective information by
challenging dysfunctional processing rules, the second component of
intervention suggested by the theoretical considerations described in
the previous sections consists of directing clients' attention to component expressive motor behaviors and underlying emotional schemata
which are not being synthesized fully into complete emotional experiences. We hypothesize that there is a direct pathway between neural
impulses and subjective emotional experience, and although we do not
believe that emotional experience is necessarily dependent upon somatic feedback, we do hypothesize that somatic feedback can cue emotional experience in therapy (Greenberg & Safran, 1986). We are thus
suggesting that in a therapeutic context people can learn to infer their
internal states through a process of monitoring their own expressive
motor behavior. In addition, we hypothesize that, while emotional experience is not necessarily dependent upon somatic feedback, it can,
and often does, play a secondary or supportive role in the synthesis of
emotional experience (cf. Leventhal, 1984).
Elsewhere, we have reviewed the literature demonstrating that a
number of therapeutic traditions ranging from focusing (Gendlin, 1978)
to gestalt therapy (Perls, 1973) to bioenergetics (Lowen, 1967) employ
techniques consisting of drawing clients' attention to their own somatic
experiences in one fashion or another (Greenberg & Safran, 1986). Al-
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Jeremy D. Safran and Leslie S. Greenberg
though it is possible that various processes such as hypnosis and suggestibility play a role in the efficacy of these procedures when then do
work, the theoretical considerations described above suggest that the
utility of interventions which direct attention to somatic changes may at
least in part be accounted for by the intrinsically expressive-motor
nature of emotional processing.
Our clinical experience is that interventions consisting of directing
clients' attention to their own nonverbal behavior and somatic changes
can be a useful and sometimes necessary adjunct in the process of
helping clients become aware of potentially adaptive emotions. Simply
teaching clients on a conscious, rational level that it is alright to experience feelings such as anger or vulnerability may not change the quality
of the conscious emotional experience, since they may be lacking a
perceptual motor skill rather than an exlusively conceptual skill. As
Zajonc (1980) argues, the memory code for emotional experience may
be more similar to the memory code for muscular action than it is to
other memory codes.
Finally, the schema model of emotional memory also suggests that
imagery plays an important role in emotional experience (cf. Leventhal,
1979) and that encouraging clients to attend to fleeting images of which
they are only marginally aware may activate cognitive-affective schemata which were previously not activated. This in turn may result in a
more comprehensive processing of an emotional experience, or in
classes of emotional experience which were previously not fully synthesized. We hope that future research will answer questions such as
"what is the relationship between conceptual processing and the activation of specific cognitive affective schemata," but it is clear at a clinical level that imagery is an excellent method of evoking emotional
memory. One cannot easily access underlying emotional schemata by
simply talking with clients about their experience. It is often more
effective to instruct the person to imagine a certain person or situation
and to then instruct them to attend to their emotional responses to the
image. A major task therefore in synthesizing new affect is one of bringing automatic processing into awareness by evoking previously unavailable schemata and attending to previously unattended to expressive
motor behaviors.
B. Challenging Maladaptive Cognitions
Although there is a variety of different procedures used in different
cognitive behavioral approaches two commonly employed procedures
are (1) accessing and exploring maladaptive cognitive processes, and (2)
challenging maladaptive thoughts and beliefs. With respect to the sec-
Hot Cognition and Psychotherapy Process
167
ond procedure, different approaches are used to challenge maladaptive
thoughts or beliefs. Beck (1976), for example, suggests that clients learn
to challenge their automatic thoughts by examining their distorted beliefs from a logical perspective, and by carefully examining the evidence
relevant to the automatic thought. Other cognitive-behavior therapists
such as Meichenbaum (1977) suggest that maladaptive thoughts can be
challenged using positive self-statements or coping thoughts.
We have found that maladaptive thoughts can also be challenged
effectively by confronting them with contrary affective experience
(Greenberg & Safran, 1986). Using appropriate therapeutic procedures,
the therapist can facilitate a process through which clients challenge
their own maladaptive cognitive processes through affective information which is generated internally. The two-chair intervention in Gestalt therapy (Greenberg, 1979, 1984; Perls, 1973) is a good example of a
procedure that can be employed to evoke adaptive emotional responses,
which can then be used to challenge maladaptive, self-critical cognitive
activity. The therapist, using skillful timing, shifts the client back and
forth between the chair in which he or she behaves in a self-critical
fashion and the chair in which he or she responds to that self-criticism.
Unlike the situation in a more standard type of cognitive-behavioral
intervention, the client in this chair is not instructed to respond to
self-criticisms in a rational fashion. Instead the client is instructed to
respond in a fashion which is consistent with the way he or she is feeling
at that moment (Greenberg, 1979). The process of relegating two different aspects of the person (i.e., the critical and the experiencing sides) to
two different spatial locations initially serves to intensify the self-criticism. As the self-criticism becomes more concrete, more specific, and
more intense, the client goes through a process of reacting to the criticisms. Often the initial reaction is one of defeat. As the conflict is intensified, however, and the client pays attention to underlying expressive
motor and schematic level processing, he or she begins to experience
adaptive emotions which challenge the self-criticism (Greenberg, 1984).
The experience of these emotions can be facilitated through procedures
described above such as directing the client's attention to nonverbal
behaviors which are not initially in awareness. This process leads to
clients becoming less self-critical and more self-compassionate. In this
dialogue clients are more able to fully experience biologically adaptive
emotions such as sadness or anger. These feelings supply the appropriate action tendency and these new action dispositions form the base for
challenging the negative cognitions. Clients in the experiencing chair
often respond to their own self-criticisms with anger or self-assertion.
Negative self-statements such as "You're no good, too weak, selfish,"
etc., are challenged by clients themselves from an internally expert-
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enced sense of confidence and validity. Here arousal of angry feelings
expressed assertively in statements such as "Stop doing this to me" or "I
want to do what I am doing" challenges the self-criticism from the other
chair and causes it to soften. Alternatively, an authentically experienced feeling of sadness or vulnerability in one chair can lead to a
softening of self-criticism from the other chair, as the client becomes
more self-compassionate. This process has been shown to be related to
positive therapeutic outcome (Greenberg, 1984).
In summary, using procedures of the type we have described, the
therapist can facilitate a process through which the client synthesizes
internal information which can be used effectively to challenge selfcritical activity. Challenging maladaptive cognitive processes through
internally generated affective information can be particularly effective
in situations wherein the client responds to logical or reality-testing
interventions with statements such as "I know that it's illogical but
that's the way I feel" or "I know that there is no evidence that I'm failing
but that's the way I feel." As Rachman (1983) suggests, there are limits to
the extent that undesirable emotional responses can be modified using
rational therapeutic procedures. We recommend the type of affectively
oriented procedure described above as a useful supplement to more
standard cognitive behavioral procedures. Internally generated information, if attended to and fully synthesized, has a compelling quality
about it which allows it to be a powerful agent in the modification and
reorganization of cognitive structures.
Goldfried and Robins (1983) took the concept of self-schema from the
social-cognition literature and applied it in a thoughtful analysis of the
nature of the change process in cognitive behavior therapy. Consistent
with available experimental research, they hypothesize that negative
self-schemata bias the processing of information in a fashion which
prevents people from attending to information that is inconsistent with
their negative self-schemata. Following this analysis, Goldfried and
Robins (1983) outlined a number of technical suggestions for ways in
which therapists can help clients to process self-schema information
that will help change their negative self-schemata.
Maladaptive self-schemata do not only bias the processing of external
information. They can also bias the processing of internal information
(Safran, 1984a,b). Thus, for example, individuals who construe themselves as always being strong and in control of their feelings may have
difficulty fully synthesizing feelings of hurt and vulnerability even
when appropriate, and acting adaptively in response to them. Allocating
attention to components of emotional experience which are previously
not fully synthesized can thus provide a client with irrevocable new
Hot Cognition and Psychotherapy Process
169
information about who he or she is and can bring about a modification in
the person's self-schema.
C. Assessing Mood-Congruent or Hot Cognitions
Another important therapeutic implication of the theoretical considerations we have outlined above is that biased or maladaptive information processing-activities may be most readily accessible when the
client is in a problematic affective state (Greenberg & Safran, 1984b,
1986; Safran & Greenberg, 1982a,b). As Bower (1981) and Teasdale and
Taylor (1981) have demonstrated, negative memories and thoughts are
most easily accessible when people are in a sad or depressed mood.
These findings can be accounted for by both the semantic network and
the schema models described above. Emotion plays an important organizational role in memory (Bower, 1981). It should come as no surprise to
cognitive therapists that clients have difficulty accessing automatic
thoughts in therapy when they are not feeling particularly depressed or
anxious at that moment. In fact, one might speculate that the fact that
cognitive therapy procedures have been slower to develop with anxiety
disorders than with depression may at least in part result from the fact
that anxious emotional states are often more situationally bound than
depressed emotional states. Since the therapeutic situation may not
readily replicate the environmental contingencies that evoke the problematic anxiety reaction, clients with situationally bound anxiety may
have more difficulty accessing automatic thoughts than the average
depressed client, who is depressed even while in the therapy session.
Our repeated observation has been that important automatic thoughts
are more readily accessible in therapy when the client is experiencing
the relevant emotional state. A variety of procedures ranging from using
role plays, to focusing upon imagery, to in vivo procedures, to working
with whatever thoughts and feelings are emerging in context of the
present relationship between the client and the therapist can be useful
for accessing emotions and associated automatic thoughts. To summarize the relevant principle concisely, the key is to work with clients in an
emotionally vivid, real, and immediate fashion. There are an infinite
number of choice points in terms of what particular situation or issue a
therapist will explore with his or her client in a given session. In our
opinion, one of the major deciding criteria should be "what is emotionally most alive for a client at any given point in time." It is not unusual
for this guideline to lead the therapist in a different direction than he or
she would go if he or she was to follow the agenda-determined approach
of Beck's cognitive therapy (Beck et αϊ., 1979). We argue that, for the
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Jeremy D. Safran and Leslie S. Greenberg
reasons described above, a predetermined agenda should not take precedence over the criterion of emotional vividness.
D. Restructuring Maladaptive Schemata
A final principle of intervention suggested by the theoretical considerations outlined above can be thought of in some ways as an extension
of the previous principle (i.e., accessing mood-congruent cognitions).
This principle can be stated as follows. Habitual, maladaptive emotional
reactions are most easily modified when the client is in the relevant
emotional state. How does our previous theoretical discussion lead to
this hypothesis? Although an important emphasis of this article has
been the potentially adaptive role that emotions play in human functioning, we in no way wish to imply that all emotional experiences are
necessarily adaptive. We hypothesize that through unfortunate learning experiences, an individual can develop maladaptive cognitiveaffective schemata. For example, as a result of consistently negative
experiences with significant figures in the past, a client may develop
maladaptive cognitive - affective schemata which become automatically activated in response to cues associated with intimacy and which,
when processed, generate anxiety and avoidance behavior.
In order to change and modify this dysfunctional emotional response
pattern, it may be necessary to restructure or reorganize the relevant
cognitive - affective schema. We hypothesize that this type of schematic
restructuring may take place most readily when the relevant schema is
fully activated (Greenberg & Safran, 1986). As Lang (1983) suggests, a
cognitive-affective schema, or what he refers to as an emotional prototype, may be thought of as a subroutine in a computer program. In order
to modify the program it is first necessary to access the relevant subroutine. Since the distinction between this point and our previous hypothesis about accessing mood-congruent cognitions may not be immediately apparent, we will elaborate further. What we are suggesting here is
that it may be important to work with clients while they are in affectively aroused states, not only because relevant cognitions are more
readily accessible in these states, but also because the affective schemata themselves will be most amenable to restructuring in these states.
Once the schema becomes activated it is possible to subject it to further
processing in conscious, focal awareness and to restructure it through
this processing.
Further processing may take various forms. It may, for example, result from a schematic accommodation in response to the information
provided by the evidence that there is no reason to be anxious in the
present situation. Or it may take the form of elaborating at a conceptual
Hot Cognition and Psychotherapy Process
171
level the implicit meaning of a specific emotional schema and then
challenging certain implications which emerge from this type of elaboration. In any event, we are suggesting that "emotional learning" or
learning in the domain of "hot cognitions" will be preferable to new
learning in the domain of "cold cognitions." While this hypothesis is
generated on the basis of theory, there is some preliminary empirical
evidence which is corroborative in nature. Orenstein and Carr (1975),
for example, found that there was a substantial positive correlation
between physiological indexes of anxiety during treatment with implosive therapy, and a decrease in self-recorded fear during a subsequent
behavioral avoidance test. Lang (1977) has also found that subjects who
were treated with desensitization showed greater improvement if there
was increased heart rate response during therapy. Also, Borkevec and
Sides (1979) found that evidence of increased anxiety in subjects during
treatment may be positively related to therapeutic outcome.
The critical reader at this point may ask, what is the advantage of the
type of schematic model of maladaptive emotional responding we are
postulating over a simple classical conditioning model? For one thing a
classical conditioning model would predict the opposite of the above
results, i.e., that an anxiety response is most readily unlearned when
the client is engaged in an incompatible response such as relaxation.
Moreover, a classical conditioning model conceptualizes problematic
emotions as learned responses. The information-processing perspective
we have outlined conceptualizes problematic emotions as more than
learned responses. They are also information with meaning. It is only
when conceptualized from this perspective that we can begin to speak
about accessing a maladaptive cognitive-affective schema so that we
can begin to restructure it through a variety of procedures. These procedures may include but are not limited to exposure treatment. Accessing
a schema allows one to, in a sense, unpack it and elaborate the meaning
of an event for oneself in more explicit terms. This in turn can lead to the
uncovering of negative appraisals or self-statements which can be challenged with more standard cognitive behavioral methods or through the
activation of adaptive emotional responses in the fashion described
earlier.
Another advantage of both the semantic network and schema models
over the classical conditioning model is that the classical conditioning
model would predict that events become associated with one another on
the basis of simple contiguity in time. Both associative network and
schema models predict that events become linked together, not only on
the basis of temporal continuity but also on the basis of different forms of
meaning similarity. In fact, recent research conducted by Bower and
Mayer (1986) suggests that emotions and memories become associa-
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Jeremy D. Safran and Leslie S. Greenberg
tively linked only when they are appraised as causally related at the
time of initial encoding. Both semantic network and schema models
thus suggest that simple exposure treatment may be inadequate to break
the linkage between different nodes in memory which are linked together. It may be necessary to clarify the nature of the link between
different nodes in memory by examining the meaning of the relevant
nodes as well as the nature of the linkage between them. We hypothesize that this process of clarification is best accomplished when the
individual is in the relevant affective state. It is only then that the client
can subject the relevant emotional experience to further conceptual
processing and extract the meaning which is implicit in it. In Section
IV,A,4 we described the fashion in which emotion functions as a type of
tacit meaning. Our position is that whether or not a particular emotion is
adaptive in a specific context, it still constitutes a type of tacit meaning
which can provide the individual with information about the impact of
an event upon him. Once this meaning is made explicit the individual
can either act adaptively in response to it or, if appropriate, question
some of the assumptions inherent in his or her perception.
VI. CONCLUSIONS
In this article we have outlined a number of theoretical considerations which we consider relevant to understanding the relationships
among emotion, cognition, perception, and action in the process of psychotherapy. It has not been our intention to present a definitive theoretical model. Rather, our objective has been to elaborate upon some of the
implications of different metatheories and different theoretical constructs and to evaluate what different metatheories and different theoretical constructs contribute to our understanding of the relevant processes. One of the major points of comparison has been between two
substantially different metatheoretical or epistemological perspectives:
the information-processing perspective and the ecological perspective.
We conclude that both metatheoretical perspectives can contribute to
our understanding of relevant processes and that neither is completely
adequate for our purposes in and of itself. We thus suggest a rapprochement between the two perspectives.
This integrative position makes some specific assumptions about the
functional significance of emotion in human functioning and also
allows us to speculate about various avenues of intervention which may
be promising. Our major assumptions are that emotional experience
plays an adaptive role in human functioning and that emotions can be
thought of as a type of tacit meaning which provides the individual with
Hot Cognition and Psychotherapy Process
173
information about the impact of events upon himself or herself as a
biological organism. The common denominator to the therapeutic avenues we have explored is that facilitating the experience of emotions in
,,
therapy and working with "hot cognitions can be useful for a variety of
reasons.
As we have argued previously, however (Greenberg & Safran, 1984b,
1986), it is important not to impose a uniformity myth upon affective
phenomena in psychotherapy. Different affective processes will be therapeutic in different contexts. It is thus important to adopt a differentiated perspective with respect to our consideration of both affective
processes and therapeutic contexts. At a more molar level we can formulate empirically testable hypotheses about individual-difference
variables which interact with specific affective processes. For example,
it may be that interventions designed to intensify affective experiences
for the purpose of accessing mood-congruent cognitions are more important for clients with emotionally overcontrolled styles than they are
for clients with emotionally undercontrolled styles.
At a more molecular level there is a need to formulate empirically
researchable hypotheses about the interaction between specific therapy
process contexts and specific affective phenomena. What specific discernible markers in therapy process inform the clinician that a specific
affectively oriented intervention will be effective (Rice & Greenberg,
1984)? Future theory, research, and practice will benefit from a careful
consideration and exploration of a variety of different kinds of affectivechange processes associated with different types of therapeutic events.
We have outlined a few of these events in this article in an attempt to
show that an integrative perspective can lead to a differentiated view of
the role of emotion, cognition, and action in the process of psychotherapeutic change.
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Causal Attributions in Health
and Illness
JOHN L. MICHELA
Teachers College
Columbia University
New York, New York 10027
JOANNE V. WOOD
Department of Psychology
State University of New York at Stony Brook
Stony Brook, New York 11794
I. Introduction
II. The Antecedents and Consequences of
Causal Attributions
A. Why Study Attributions?
B. Attribution Theories and Attributional Theories. .
C. Mediators of the Effects of Attributions
upon Outcomes
III. Attributions in Health and Illness Behavior
A. Prevention and Recovery Behaviors
B. Symptom Interpretation
IV. Attributions in Adjustment to Illness
A. Antecedents of Attributions for Illness or Injury . .
B. Consequences for Adjustment to Illness
V. Implications for Theory, Research, and Intervention . .
A. Theoretical Progress
B. Possible Directions for Research Methods
C. Applications to Health Interventions
References
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I. INTRODUCTION
The question "Why?" arises frequently in our everyday lives. This
search for causes may be particularly insistent when it concerns matters
as important as one's physical well-being. A woman who feels a piercing
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AND THERAPY, VOLUME 5
Copyright © 1986 by Academic Press, Inc.
All rights of reproduction in any form reserved.
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John L. Michela and Joanne V. Wood
pain in her stomach wonders whether a recent meal could be responsible. A novice jogger who tolerates exhaustion and sore muscles probably believes that exercise has a causal influence on health. A teenager is
likely to ask "Why me?" after a paralyzing accident.
The search for causes is the topic of attribution theory. This theory,
which emerged in the mid-1960s, provides some of the foundation for
today's increasing emphasis on cognition in social, clinical, and health
psychology (e.g., Fiske & Taylor, 1984; Kendall & Hollon, 1979; Wyer &
Carlston, 1979). In this article, we review studies of causal attributions
in health and illness, which we will organize in terms of several theoretical models and issues drawn from the literature on attribution theory
and health psychology.
First, in Section II, we will provide an introduction to attribution
theory and the concepts that will be applied throughout the article.
Section III will cover applications of attribution theory to behavior in
health and illness, and Section IV primarily will consider
emotional
responses to illness as mediated by attributions. Section V will highlight
the major conclusions from Sections III and IV, and implications will be
drawn for theory, research, and cognitive-behavioral therapy.
One question we do not address is whether attributions play an etiologic role in illness. An answer will require advances in models of psychobiological pathways from cognitions to illness. Discussions of this
matter appear in Cohen and Lazarus (1979), Janoff-Bulman and LangGunn (1986), and Jones (1982).
II. THE ANTECEDENTS AND CONSEQUENCES OF
CAUSAL ATTRIBUTIONS
The term attribution usually refers to inferences that people make
about the causes of events or of states of being. These inferences require
the acquisition and processing of information about possible causal factors and about the event or state that has been caused (Kelley, 1967,
1972a). Attribution also refers to the inference of whether a person
possesses traits or dispositions to act in particular ways (Jones & Davis,
1965), which is especially relevant to interpersonal situations. For example, a person who has been helped unexpectedly by another may
consider whether the other person's action derived from a disposition to
1
be helpful or from the other's desire to obtain a favor in return. Attribu1
Attribution has become such a popular term among psychologists that it is sometimes
used interchangeably with cognition—even though many cognitions are not attributions
in either of the senses described above. In accord both with theorists' and dictionaries'
Causal Attributions in Health and Illness
181
tion research has been reviewed in detail elsewhere (e.g., Harvey &
Weary, 1984; Kelley & Michela, 1980; Schneider, Hastorf, & Ellsworth,
1979), so our purpose in this section is to introduce concepts relevant to
our subsequent review of attributions in health.
A. Why Study Attributions?
1. The CentraJity of Attributions in Understanding the World
Attribution is a powerful theoretical construct within contemporary
cognitive analyses of human experience and behavior. These analyses
hold that people use their understanding of the world to interpret new
information and to make decisions about action. Often a causal analysis
is critical to this understanding, because it can provide a succinct representation of the information necessary for interpretations or decisions.
As a simple example, a person may infer that a particular food causes
indigestion. This attribution encapsulates, from a potentially vast set of
information about foods and one's own body, that the particular food
produces a particular effect on the body. Moreover, the person now has a
means of preventing further illness episodes by avoiding the offending
food. Heider's seminal work clearly articulates the general point here:
The idea that our cognitions, expectations, and actions are based on a mastery of the
causal network of the environment is, of course, the main tenet of . . . this essay.
(Heider, 1958, p. 59)
An underlying assumption in Heider's and others' theorizing is that
people are sufficiently rational to regulate their actions in accord with
their understanding of the causal structure of the world.
2. The Possible Predominance of Factors Other Than Attributions in
Psychological
Phenomena
Despite assuming that attributions are key cognitions, attribution
theorists have been cautious in their appraisal of the influence of attributions relative to the influences of other factors upon psychological
phenomena. For example, Heider (1958) noted at the end of his book that
he had dealt mainly with the "intellectual" side of life. In the introduction to an important collection of early papers in attribution theory,
Jones, Kanouse, Kelley, Nisbett, Valins, and Weiner (1972) added:
definitions of attribution we will restrict our use of the term to inferences about causes or
about characteristics of people or things having the potential for causal influence. This is
not a very severe restriction, given the wide range of characteristics that may come under
consideration in causal analysis.
John L. Michela and Joanne V. Wood
182
Perhaps the most that can be reasonably claimed is that attributional analyses may be
propaedeutic to the application of other theories, for the simple reason that attributions arouse a diversity of other motives and mediate numerous other processes —
such as aggression, guilt, or motivational changes, (p. xii)
It is partly an empirical question whether attributions make an important contribution to other processes in natural settings. It seems likely
that many factors influence the magnitude of the effect of attributions
upon how people understand or react to events, and fuller knowledge of
this matter will be some time in coming.
By taking a modest stance about the practical significance of attributions, attribution theorists have avoided falling prey to a distorting tendency described in laypersons' causal analyses. People generally recognize too few causes relative to the host of factors often operating upon
phenomena, with a particular bias toward locating causality within
persons instead of situations (cf. Nisbett & Ross, 1980).
B. Attribution Theories and Attributional Theories
The field of attribution has been divided into two broad areas: attribution and attributional theories (Harvey & Weary, 1984; Kelley & Michela, 1980). First, attribution theories focus on the antecedents of attributions, i.e., the factors leading to the particular attribution formed (e.g.,
Jones & Davis, 1965; Kelley, 1967). For example, a man may seek a causal
explanation after learning he has lung cancer, ultimately inferring either that he is personally responsible for the disease or that factors in the
environment are responsible. Second, attributional theories concern
various consequences of attributions for the attributer. Research on
consequences examines the impacts of attributions on other beliefs, on
affects, and on behavior.
In order to illustrate how some of the theoretical problems have been
addressed, the following two subsections list some of the kinds of analysis that have been used with antecedents and consequences of attributions. Readers unfamiliar with attribution theory may wish to consult
much fuller treatments using this organization (Harvey and Weary,
1984; Kelley and Michela, 1980).
1. Antecedents
a. Information Processing. A great deal of theoretical and research
interest has centered on the kinds of information used in making attributions and the ways this information is processed. Following Heider
(1958), who built upon the scientific canons of John Stuart Mill, Kelley
(1967) proposed that the lay attributer's causal analysis is analogous to
that of the scientist. Kelley's covariation principle states that an effect
Causal Attributions in Health and Illness
183
(i.e., an outcome or event) is attributed to the factor seen to have been
present when the effect was present and absent when the effect was
absent. If the attributer's observations occur across time, information
becomes available about consistency, i.e., whether the effect consistently is present when the potential cause is present. For example, a
woman seeking an explanation for recurrent stomach pains could examine whether some aspect of her behavior (eating spicy tamales) or a
particular environmental condition (going to Rosita's restaurant) regularly occurs close in time to the pains. Observations across persons yield
consensus information (whether other persons at the restaurant get
stomach pains), and observations across stimuli yield information about
distinctiveness (whether other restaurants or other foods precede stomach pains). Particular combinations of high versus low consistency,
consensus, and distinctiveness information have been found to lead to
particular attributions of causality (e.g., McArthur, 1972). Thus, if (1) a
person consistently responds to an illness stimulus by becoming ill (high
consistency), (2) most other people do not react to it in that way (low
consensus), and (3) the person reacts to many other stimuli in that way
(low distinctiveness), then the person would be seen as constitutionally
disposed to the illness. However, if on most occasions, most other persons also reacted to a distinctive illness stimulus, the stimulus would be
seen as the causal origin.
Several more primitive principles of information processing also have
been described. For example, potential causes may be rejected if they
are too far apart in time from the effect or too dissimilar with respect to
the effect, as when a seemingly small cause is doubted for a monumental
effect. In the nineteenth century, colleagues of the physician Ignaz
Semmelweis rejected his notion that uncleansed hands were the cause
of puerperal fever.
b. Beliefs.
A person's prior beliefs and schemata have major impacts
on the making of attributions. Kelley and Michela (1980) proposed the
term causal suppositions for beliefs about the likely cause whenever an
effect is observed; causal expectations concern the expected effects
whenever a particular causal force is observed. Such beliefs might be
acquired from cultural teachings, personal experience, and other learning processes.
A causal schema is a conception of how two or more causes may
combine to produce an effect (Kelley, 1972b). According to the "multiple
necessary causes" schema, for example, extreme effects such as success
on difficult tasks are thought to require multiple causes (i.e., both
extreme effort and ability on the task are required; Kun & Weiner, 1973).
According to the discounting principle, "the role of a given cause in
producing a given effect is discounted if other plausible causes are also
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present" (Kelley, 1972a, p. 8). One of many phenomena that has been
interpreted though this principle is the finding that very physically
attractive women do not have particulary high self-esteem, despite the
fact that they tend to receive disproportionate status and other rewards
(Berscheid & Walster, 1974). Research has suggested that these women
discount their own abilities as a cause of their rewards, attributing these
rewards partially to their beauty—which is less worthy of esteem
(Major, Carrington, & Carnevale, 1984; Sigall & Michela, 1976). The
augmentation principle holds that people assume a causal force toward
an observed outcome to be especially strong if the presence of an opposing causal force also has been observed (Kelley, 1972a). Thus, people
who contract influenza after doing preventive activities such as getting
adequate rest or nourishment may conclude that flu is particularly
virulent.
c. Motivations. Motivations have been analyzed both for their effects in instigating attribution processes and in influencing the particular attributions formed. People may make attributions as a manifestation of motivation to obtain a veridical understanding of the world, or
they may be biased so as to encourage and facilitate "effective exercise
of control in that world" (Kelley, 1972a, p. 22). The attributer may have a
"stake" in the causal explanation for an event depending upon such
factors as whether the person's self-esteem might suffer, as when an
undesirable event may be the person's own fault. In addition, a person
may try to arrange the information available to others so as to make a
more desirable impression (see Harvey & Weary, 1984). However, some
writers (e.g., Miller and Ross, 1975) have warned that many apparent
cases of motivational bias in attribution may actually result from imperfect cognitive processes.
2. Consequences
Do attributions mediate other cognitions (e.g., expectancies), affects,
motivations, and behaviors? Laboratory and field research has sought to
demonstrate this influence in a variety of domains, including achievement (Weiner & Kukla, 1970; Weiner, Frieze, Kukla, Reed, Rest, & Rosenbaum, 1972), parole decision making (Carroll & Payne, 1976), loneliness (Peplau, Russell, & Heim, 1979), learned helplessness (Abramson,
Seligman, & Teasdale, 1978), and, of course, health and illness.
Weiner's analysis (e.g., Weiner et αϊ., 1972) of attributions in achievement is paradigmatic. A picturesque example might involve the causal
analysis for a person's failure to execute a swan dive that resulted in a
belly flop. This unpleasant outcome could be due to personal factors
such as lack of skill or lack of trying, or to environmental factors such as
the difficulty of the task or chance events (e.g., a gust of wind). Weiner
Causal Attributions in Health and Illness
185
recognized that these specific causes each had different locations in a
two-dimensional scheme of internal versus external locus of causality
and temporally stable versus unstable causality. (The gust of wind
would be an unstable cause.) Ability and effort are both internal causes
but only ability is stable; task difficulty and chance are both external but
only task difficulty is stable. Each attributional dimension is, in theory,
linked with a particular class of outcomes. Weiner (1979) reviews evidence that causal stability is linked with expectations, such that attributions to stable causes lead to expectations of similar desired or undesired outcomes in the future. Internality of cause is linked primarily
with affects, e.g., if an undersirable event is attributed internally (as
opposed to externally) this may magnify reactions such as guilt or unhappiness.
C. Mediators of the Effects of Attributions upon Outcomes
In many applications of attribution theory to health and other problem areas, the focus is on consequences of attributions as mediated by
other perceptions, cognitions, or motivations tied to attributions. The
nature of these mediators depends upon the outcome and context under
examination. For example, in Weiner's (1979) work a key outcome is
achievement strivings. Within Weiner's framework, one of the immediate determinants of achievement strivings is the expectation that one
can control whether a desired outcome will be obtained, e.g., through
effort. Specific attributions are theorized to exert their effects upon
achievement behavior through their implications for personal control
or efficacy, or through other mediators. In other words, attributions are
meaningful
in that they contribute to subsequent inferences the attributer may make. These further inferences may govern behaviors or
emotional experiences.
We propose more generally that the effects of attributions upon an
outcome are most understandable in the context of a more encompassing model of the outcome's determinants, such as the cognitivemotivational model in Weiner's analysis of achievement strivings. The
more encompassing model identifies the mediators of the outcome
which, in turn, are influenced by causal attributions. For example, as
we will discuss further in Section III, a popular model for the analysis of
preventive health behaviors is Bandura's (1977) social learning theory.
Within social learning theory, self-efficacy is considered to be an important mediator of behavior. Thus, if attribution processes influence selfefficacy, self-efficacy may provide a pathway from attributions to behavior.
One implication of our analysis follows from the possibility that a
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John L. Michela and Joanne V. Wood
particular cause of an event may have different meanings to different
people; these meanings of the " s a m e " cause could lead to different
effects for the different attributers. Another implication is that a person
need not arrive at a specific cause in order for attribution-based effects
to occur. A person's causal analysis may progress merely to a stage at
which a mediator of an outcome is influenced, as in the case of a person
concluding, "Whatever the cause may be, I know I can't control what
happens." In such instances, the person's causal analysis may already
have set in motion the process by which an outcome is affected (cf.
Michela, Peplau, & Weeks, 1982). T h e major implication of this analysis
is that the underlying mediators for the outcome, context, and persons
under study should be specified as fully as possible in applications of
attributional perspectives.
III. ATTRIBUTIONS IN HEALTH AND ILLNESS BEHAVIOR
This section will present attributional analyses of (1) motivation to
perform preventive health behaviors (primary prevention), (2) motivation of behaviors directed toward becoming well or maintaining health
after a diagnosis of illness (recovery and secondary prevention), and (3)
cognitive processes involved in interpreting symptoms of illness.These
three topics correspond with the three categories of health-related behavior proposed in the influential work of Kasl and Cobb (1966a, b). Kasl
and Cobb defined health behavior as activities undertaken to prevent
disease or to detect disease in an asymptomatic state. Sick role behavior
was defined as action directed toward becoming well, undertaken by
persons believing themselves to be ill. Between these two extremes
along a wellness-illness continuum, illness behavior was defined as
activities by persons attempting to determine whether they are ill or
how to obtain treatment.
We will begin with a description of the theoretical frameworks that
psychologists apply most frequently to health behaviors. This description focuses on the cognitive constructs in these frameworks that are
most promising for developing connections with attribution theory.
A. Prevention and Recovery Behaviors
Within recent years it has become widely recognized that personal
behaviors in food choices, cigarette smoking, exercise, seat belt use, and
other domains of activity have great significance for preventing the
onset of illness or injury (Matarazzo, 1982; Office of the Assistant Secretary for Health, 1979).
Causal Attributions in Health and Illness
187
1. Cognitive Theories of Motivation Often Applied to Health
The health belief model (Janz & Becker, 1984) and social learning
theory (Bandura, 1977) are two of the most widely used perspectives for
analyzing preventive health behaviors. Both of these models rely heavily on cognitions as mediators of behaviors, but few investigators have
tried explicitly to connect these frameworks with attributional models
of motivation. Rosenstock (1974) traced the health belief model back to
its origins in the e x p e c t a n c y - v a l u e model of motivation (e.g., Lewin,
Dembo, Festinger, & Sears, 1944). The e x p e c t a n c y - v a l u e theorists posited that people decide among behaviors according to evaluations of
the subjectively expected utility of each behavior, selecting the behavior that offers the greatest utility or "payoff." Theoretically, each behavior's utility is a function of the hedonic value of the outcomes of the
behavior and the subjective expectancy that desired outcomes will be
realized as a consequence of performing the behavior.
a. The Health Belief Model. In contemporary versions of the health
belief model (Becker, 1974), the specific concepts used to operationalize
the expectancies and values relevant to health actions include "perceived susceptibility" to contracting a disease, "perceived severity" of
the consequences of the disease, and "perceived benefits" of health
actions. King (1984) has suggested that attributions about causes of an
illness could be precursors to these beliefs. For example, a person might
believe that a particular illness is caused by a particular behavior, so the
person's assessment of susceptibility would depend on whether he or
she typically engaged in this behavior. King also theorized that the
effects of attributions on health behaviors are both indirect — mediated
by beliefs commonly considered in health belief models — and direct or
unmediated by those beliefs. Unfortunately King's initial studies did not
provide a clear picture of the underlying aspects or dimensions of causal
perceptions, such as internality, stability, and so forth, that lead to particular kinds of health beliefs. For example, it was unclear why attributions of high blood pressure to internal causes were associated with
perceived benefits of blood pressure screening.
b. Bandura's Social Learning Model. The model that seems most
amenable to a variety of connections with attribution theory is Bandura's (1977) social learning theory, which implicitly draws upon
e x p e c t a n c y - v a l u e concepts and also has origins in the previously dominant approaches to learning, classical and operant conditioning. In his
analysis of cognitions that mediate behavior, Bandura distinguished
between outcome expectations and efficacy expectations. Outcome expectations are concerned with whether performance of a given behavior
is believed to yield a given outcome. For example, a man's belief in
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John L. Michela and Joanne V. Wood
whether particular lifestyle changes improve cardiovascular functioning is hypothesized to influence his motivation to make those changes.
In causal attribution terms, this mediator of behavior is whether the
man believes that those lifestyle changes cause improvement in health
— a "causal expectation" (Kelley & Michela, 1980). Efficacy expectations in Bandura's theory are concerned with whether the man perceives himself to be able to enact the behavior if he were motivated to do
so by the outcome expectation (e.g., he may know that stopping smoking
would be beneficial, but thinks he would fail at quitting).
Bandura contends that people learn the extent of their self-efficacy in
specific behavioral domains through personal and vicarious experi2
ences. For example, an overweight man could learn from repeated,
failed attempts to lose weight that he lacked the ability to do so. The
antecedents of this inference are one focus of attribution theory analysis, and it seems likely that the kinds of beliefs, motivations, and information-processing mechanisms described in Section II would operate in
this case. Schunk and Carbonari (1984) have suggested that attributions
to ability, an internal and stable cause (Weiner, 1979), are most closely
related to self-efficacy. Schunk and Carbonari also indicate that other
attributions may provide information about self-efficacy, e.g., when a
person holds a causal supposition that weight loss requires more effort
than he or she is able to exert.
c. Locus of Control. The social learning analysis of Rotter and others
(Rotter, Chance, & Phares, 1972) gave rise to the construct of generalized
expectancies for internal versus external locus of control of reinforcement (Rotter, 1966) and multidimensional health locus of control (Wallston & Wallston, 1982), which have been the subject of considerable
research in recent years. However, the construct of "internal versus
external locus of control of reinforcement" seems less amenable to
translation into traditional attributional terms (Ickes & Layden, 1978)
than the e x p e c t a n c y - v a l u e formulation that underlies the Rotter et α J.
(1972) model. Rotter (1975) explained that the original internalexternal ( I - E ) scale (Rotter, 1966) was developed for the purpose of
2
Two other ways of acquiring self-efficacy beliefs are verbal persuasion and emotional
arousal. Bandura (1977) asserts that the effects of verbal persuasion are likely to be "weak
and shortlived" (p. 82). Bandura considers emotional arousal to influence self-efficacy
through attribution processes, as when a client in treatment for a phobia infers fear to be
relatively low because emotional arousal is regarded as low. In such a case, the person
would tend to have enhanced self-efficacy for approaching the feared stimulus object.
However, Bandura expressed doubts that therapeutic interventions based on attribution,
such as inducing reattributions of emotional arousal to sources other than the feared
object, would be as effective as treatments involving actual personal and vicarious experiences.
Causal Attributions in Health and Illness
189
improving the prediction of behavior in experimental situations in
which subjects' individual differences in generalized expectancies for
control of reinforcement might enhance or impede the effects upon
expectancy that the experimental situation was designed to generate.
To date, attribution theorists have not given a great deal of attention to
issues of attributional styles and individual differences, though there
are exceptions to this rule (e.g., Cutrona, Russell, & Jones, 1984; Dweck
& Goetz, 1978).
d. Comments. Health and illness behaviors are not mediated completely by rational or cognitive processes, and analysts in the health
belief and social learning traditions have included sociodemographic,
biologic, and other kinds of influences in their models of specific health
behaviors. Thus, we do not wish to give the impression that cognitive
factors are more important than, say, biologic ones, particularly for
behaviors with determinants as complex as those of cigarette smoking
and food choice. Nevertheless, on theoretical grounds it appears that
measurement of the various aspects of perceived causality, expectancies, and behavior, as just discussed, would be useful in studies of health
and illness behaviors.
2. Primary Prevention
Only on the topic of smoking behavior could we find studies of primary prevention in which the measures of possible cognitive influences
on behavior were conceptualized by the investigators as causal attribution measures.
Eiser's (1982) research asks whether subgroups of smokers exist for
whom particular kinds of informational interventions seem likely to
facilitate smoking cessation, and whether particular causal beliefs
should be targeted for change. Eiser obtained support for the potential
usefulness of informational interventions from a postal survey (N =
1800 at 1-year follow-up). In line with expectancy-value models, the
predictors of success in smoking cessation, by persons who requested
self-help information by mail, included beliefs in the likelihood of
avoiding cancer through smoking cessation (expectancy) and in the
importance of avoiding cancer (value).
Eiser's attributional analysis focused on three aspects of perceived
causality for failure in attempts at smoking cessation. First, the postal
survey assessed self-perceptions of the extent of being "addicted" to
smoking. Second, the temporal stability of reasons why "so many
smokers fail when they try to stop smoking" was calculated as a sum of
the rank scores of two unstable or changeable causes (lack of trying and
Jack of knowledge of what to do) minus the sum of ranks of two stable
causes [difficulty and personality,
i.e., "because of the kind of person
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John L. Michela and Joanne V. Wood
they are"). Finally, these same four causes were recombined into an
index of internality of cause, in which the external causes were difficulty and lack o/knowledge (under the assumption that in the context of
a self-help program, it is up to "other people" to provide the knowledge
of how to quit).
Eiser found that smokers "who saw themselves as more addicted, and
made more stable attributions for failure, had lower expectancies of
success and less firm intentions to stop" at the time of the initial survey
(Eiser, 1982, p. 291). The association of causal stability but not internality with expectancies of success was of particular interest because it
supported Weiner's (1979) emphasis on causal stability. Success in
smoking cessation for 1 year was predicted by higher expectations of
success. More directly relevant to attributional analysis, successful
quitters also had rated themselves as less addicted than unsuccessful
quitters. These findings led Eiser to express concern about smoking
being portrayed in some quarters as an addiction or a disease. He maintains that the antecedents
of attributions for success or failure outcomes
in attempts at smoking cessation lie in mass and interpersonal communication, thus, messages should be designed to instill beliefs in the value
and efficacy of particular, personally controlled actions to stop smoking.
However, a rather different interpretation may be made of the association between self-ratings of addiction and success in smoking cessation. T h e rating of addiction may have been essentially veridical in the
sense that the biologic or other influences on smoking that are part of
addiction (but not the cognitive influences) may have been responsible
for relapse. The essential question, which also applies to studies of
attributions in other areas, is how a correlation between a measure of an
attribution and a behavior or other outcome is to be interpreted. Does
the correlation demonstrate that the attribution led to further processes
in motivation, emotion, and so forth, or is it more likely that the measure
of attribution captures a state of the world (or of the person) that exerts
effects through separate processes of mediation? This is not a problem in
true experiments, in which the presentation of information antecedent
to attributions is manipulated. Mediation analysis and other approaches
to be discussed in Section V would help resolve this question.
The issue of whether smoking should be viewed as an addiction also is
related to the contemporary question of whether smoking cessation
treatments should include use of nicotine chewing gum. An attributional analysis suggests that a hazard in use of the gum is the possibility
that smoking cessation would be attributed to the gum instead of to one's
personal ability or motivation (Harackiewicz, Blair, Sansone, Epstein, &
Stuchell, 1985). In a review of related theoretical and empirical work,
Causal Attributions in Health and Illness
191
Kopel and Arkowitz (1975) argued that behavior change is more likely to
be maintained when it is attributed to oneself.
Finally, Goldstein, Gordon, and Marlatt (1984) have begun to examine
the possible role of attributions in whether a single "slip" after smoking
cessation leads to full relapse of smoking. The hypothesis is that internal, stable, and global attributions promote relapse, much as these attributions are held to promote learned helplessness (Abramson et αϊ.,
1978).
3. Recovery and Secondary Prevention
Much of the motivational analysis of behaviors in primary prevention
applies also to secondary prevention and recovery behavior. A limitation of this analysis in the context of illness is that rational processes
may give way to defensive avoidance or denial (Janis & Rodin, 1979).
However, the extended time course of several serious illnesses may
permit many or most patients to achieve sufficient emotional adjustment so as to engage in health-enhancing behaviors. Here we review
studies of these behaviors. Unfortunately there are few; most studies of
attributions in illness have focused on emotional adjustment, sometimes including a behavioral component and sometimes not.
A vis's (1984) study of 35 coronary bypass surgery patients examined
correlations between ratings of specific causes of heart disease (e.g.,
poor diet, lack of exercise) and self-rated compliance with medical recommendations for recovery (e.g., smoking cessation, dietary change).
Several of these correlations were consistent with the notion that compliance is enhanced when the attribution promotes a belief in control
over the disease. A more global measure of self-blame for illness also was
positively associated with recovery behaviors in Avis's results.
Plotkin-Israel (1984) examined attributions and behaviors of 30 hospital inpatients who had sustained a heart attack or myocardial infarction
(MI). Patients' ratings of their own contribution to their heart attack
were positively associated with self-ratings of motivation to aid recovery and compliance. However, when the same patients were rated by
nurses for their degree of cooperation, interest in information about the
illness, and similar behavioral and motivational measures, a negative
association was found between these ratings by nurses and patients'
ratings of their own contribution to heart attack. One of Plotkin-Israel's
hypotheses for the latter finding is that the patients claiming more internal causality and, presumably, control, were also more difficult for
nurses to manage within the hospital setting. These results resemble
one of the patterns of hospital patient behaviors that Taylor (1979) predicted from a reactance theory perspective.
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John L. Michela and Joanne V. Wood
Bar-On (1986) examined the relation of attributions to objective indicators of extent of recovery from MI (e.g., return to work) along with
self-rated recovery of 89 male patients in Israel. The men who attributed
the MI to fate and luck had substantially poorer rates of return to work
and other functioning.
Michela's (1986) results from coronary patients' self-ratings were similar to those of the previous investigators in supporting a positive association between perceived control and recovery behaviors. Forty MI patients were interviewed at an average of 11 months post-MI about their
beliefs, emotions, and behaviors at the time of the interview and, retrospectively, about the time soon after the MI. Attributions for the cause of
the MI were measured in terms of specific causes (e.g., smoking) and
causal dimensions (e.g., internality, controllability) as perceived by the
person at the time of the interview. Ratings of controllability of the
cause of the MI were positively related to compliance during the weeks
soon after hospital release. However, by the time of the interview, attributions were no longer related to compliance, and self-rated compliance
had reduced significantly from its level soon after MI. One salient possibility for the different picture at 11 months post-MI is that the disincentives to compliance with recommended lifestyle changes become, over
time, more influential as compared with the incentives; if this were so,
attributions would become irrelevant and compliance would decline.
A study of compliance with chemotherapy by 51 breast cancer patients (Taylor, Lichtman, and Wood, 1984a) suggests that causal expectations for health-related behaviors determine compliance. In this
study, the rate of compliance was so high (92%) that statistical prediction of compliance by attributions was impossible. Taylor et αϊ. speculated that causal expectations, i.e., that the treatment will improve
health, may be enhanced by informational cues associated with chemotherapy. These cues come from the location of treatment in a medical
setting with its professional treatment providers, use of medication, and
associated technology. Clearly this image of cancer treatment contrasts
strongly with the mundane changes in lifestyle (e.g., exercise and dietary change) that are recommended after a heart attack. Present data
do not tell whether this difference in "images" influences differences in
rates of compliance for these diseases.
4. Conclusion
Although relatively few studies are presently available to test linkages of attributions with health behaviors, we were nevertheless impressed that the findings were generally consistent with the attributional and motivational concepts presented earlier. These findings need
not have been so highly expected given the cautionary statements about
Causal Attributions in Health and Illness
193
attribution-behavior linkages in Bern (1972), Jones et al. (1972), Nisbett
and Wilson (1977), and Taylor (1981). In some instances where the predicted findings were not obtained, post hoc accounts of these failures
suggested that the necessary conditions for observing attributionbehavior linkages had not been met.
B. Symptom Interpretation
A person's experience of physical symptoms involves many of the
antecedent processes in attribution described earlier. The person must
combine information received from the body, the environment, and
from preexisting beliefs in order to determine the significance of physical sensations. The individual asks, "Did a physical illness cause these
sensations?"
There are several lines of evidence pointing to a major effect of psychological factors on the interpretation and response to physical sensations. For example, bodily symptoms often are reported when no detectable physiological change has occurred, as in the phenomenon of
phantom limb pain (Leventhal & Everhart, 1979). Moreover, physiological changes frequently are not accompanied by complaints of physical
symptoms. While the crushing pain of angina is thought to be brought
about by cardiac ischemia, for example, "silent" ischemia is also frequent, in which the heart is receiving insufficient oxygen but no pain is
reported. In addition, the correspondence between the extent of physiological change and the perception of physical symptoms may be quite
low. A well-known example is Beecher's (1959) study of combat soldiers
wounded in battle, in which their degree of pain was poorly correlated
with the severity of their injuries. Ample experimental evidence of this
phenomenon exists (see Skelton & Pennebaker, 1982, for a review).
Excellent treatments of symptom interpretation and closely related
topics appear elsewhere (e.g., Morris & Kanouse, 1979; Pennebaker,
1982). Here we will review selected aspects of symptom interpretation
that illustrate attributional processes in whether physical sensations are
noticed, whether they are labeled as symptoms of illness, what particular illness they are ascribed to, and what responses follow these inferences.
1. Antecedents of Symptom
Interpretation
a. The Search for Causes of Symptoms. New symptoms often fit the
conditions thought to prompt attributions, namely, novelty, uncertainty, unexpectedness, and threat (see Langer, 1978; Weiner, 1985). A
crushing chest pain, for example, will surely be perceived as very unusual and threatening to most people. Attribution processing also be-
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John L. Michela and Joanne V. Wood
comes necessary as symptoms are often vague and open to multiple
interpretations. A stomachache may signal indigestion, food poisoning,
intestinal flu, or appendicitis.
How an individual interprets symptoms may be influenced by a multitude of factors, including culture, personality, and social interactions.
There are wide cultural differences in the symptoms that are experienced and in beliefs about the diagnosticity of particular symptoms for
particular illnesses (e.g., Zola, 1966). Social interactions also influence
one's interpretation of symptoms (Skelton & Pennebaker, 1982). After
hearing that a particular illness is "going around," for example, one may
be more attentive to bodily sensations that might be associated with the
illness (Colligan, Pennebaker, & Murphy, 1982).
Several personality variables have been linked with symptom interpretation, including private self-consciousness (Pennebaker & Skelton,
1978), repression-sensitization (Byrne, Steinberg, & Schwartz, 1968),
and Type A behavior (Matthews, Siegel, Kuller, Thompson, & Varat,
1983). In addition, various aspects of the situation have been found to
influence one's experience of symptoms. When the external environment is either "quiet" (e.g., nonnovel or boring), or overwhelming,
individuals report more intense physical symptoms (Pennebaker & Brittingham, 1982; Pennebaker & Lightner, 1980). Whether one is engaged
in a task may also influence one's experience of symptoms. Weidner and
Matthews (1978) demonstrated a person-by-situation interaction in
which Type A individuals experienced fewer symptoms while they
were engaged in a task.
b. The Origins of Hypotheses and Beliefs
about Causes of
Symptoms. Beliefs about causes of symptoms may be acquired
through various learning experiences. From previous experience with
an illness, a person may associate particular symptoms with the illness
(Skelton & Pennebaker, 1982). For example, a person who experienced
stomachaches and vomiting diagnosed as intestinal flu may, months
later, more readily interpret new stomach twinges as caused by flu. In
addition, mass media presentations of advances in medical knowledge
also create awareness of new labels (Morris & Kanouse, 1979). For example, since the outbreak of toxic shock syndrome in the late 1970s, menstruating women might watch carefully such symptoms as headache,
which they earlier might have ignored. Finally, it is apparent that patients under treatment for illness may learn from health care providers
how to explain various sensations.
c. illness Models and Schemata. These learning experiences may
contribute to the development of cognitive schemata about illnesses.
Recently, researchers of symptom interpretation have begun to use the
concepts of "schemata" and "models of illness," which imply the exis-
Causal Attributions in Health and Illness
195
tence of complex cognitive structures that store and guide the processing of illness-relevant information. Leventhal and colleagues (e.g., Leventhal, Nerenz, & Straus, 1980) have proposed that a person's model of
an illness has four components. One is the "identity" of the illness — a
name that aids access to the rest of the information about the illness.
Another component is the "time course" of the illness — how long the
illness is supposed to persist and, perhaps, beliefs about the changes that
typically occur during the course of the illness. A third component is a
set of beliefs about the "cause" of the illness, which has many implications, e. g., for prevention and treatment of the illness. Finally, expected
"consequences" of the illness are prominent in the model; these latter
beliefs constitute "causal expectations" and may influence one's motivation to act in response to symptoms or other information about illness.
Support for these categorizations comes primarily from case illustrations drawn from interviews with cancer patients, diabetes patients,
cardiac bypass surgery patients, and hypertensive patients (e.g., Nerenz
& Leventhal, 1983). Also, Lau and Hartman (1983) have presented data
in support of Leventhals four categories for more mundane illnesses
and have offered evidence for an additional category, "cure" — how one
goes about recovering from the disease.
Leventhal theorizes that a model of illness comes into play as the
person engages in "self-regulation" in pursuit of health. The inferences
and decisions necessary in taking health-related actions require a good
deal of concrete knowledge about illness, which Leventhal and associates (e.g., Leventhal & Hirschman, 1982) believe is organized by the
abstract categories they have described in illness schemata. Leventhal
has argued that this self-regulation analysis constitutes a substantial
extension from the e x p e c t a n c y - v a l u e formulation described earlier, in
that more of the contents and processes of cognition relevant to health
and illness behaviors may be described in relation to the self-regulation
framework.
d. The Search for Symptoms. In addition to aiding the interpretation
of symptoms, models of illness can lead to the experience of symptoms.
A man given a diagnosis of heart disease for prior experiences of chest
pain may then begin to notice other symptoms associated with heart
disease, such as breathlessness. Or a patient who has been diagnosed as
hypertensive, which is considered to be a "silent" or asymptomatic
disease, may then begin to notice physical symptoms. It is not that such
patients are fabricating physical symptoms. Rather, the healthiest
among us can probably notice an ache here or there or feelings of fatigue
at any given time. If one is diagnosed with serious illness, one may then
be more attentive to such physical sensations, and may then label them
as indicative of illness.
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John L. Michela and Joanne V. Wood
Similarly, taking a new medication may prompt an individual to look
for physical sensations if one's model for medications holds that they are
usually associated with side effects (Morris & Kanouse, 1979). Physicians are reluctant to inform their patients of possible side effects of
drugs, in case patients would experience symptoms that otherwise
would not be noticed. However, there is evidence against suggestion
effects. Morris and Kanouse (1982) gave hypertensive subjects a leaflet
describing possible side effects of their thiozide drug treatment. A suggestion hypothesis predicts that patients informed of possible side effects
would experience more symptoms than would patients not so informed.
Morris and Kanouse (1982) pitted this hypothesis against an attributionlabeling hypothesis, which predicts that patients experience similar
symptoms, but label them according to what they think is the cause of
the symptom. Contrary to a simple suggestion interpretation, patients
who had received the leaflet reported approximately the same number
of symptoms as those who had not. Moreover, these same patients were
especially likely to attribute their experienced reactions to the medication.
e. Selective information Seeking. Schema-driven processes of symptom interpretation have been further elaborated in Skelton and Pennebaker's (1982) work. They suggest that once a hypothesis for one's
symptom is tentatively adopted, one's further attributional search is
biased so as to confirm that hypothesis (see also Rodin, 1978). For example, suppose Alfred notices a dull pain in his chest that may be interpreted as either indigestion or heart problems. If he initially adopts the
hypothesis that he is suffering from indigestion, he will selectively focus
on symptoms that are consistent with indigestion, such as stomach
cramps. If, on the other hand, his neighbor recently suffered a heart
attack, he may be attentive to other symptoms of heart attack, such as
pain in the upper arm. Evidence supporting the presence of a confirmatory bias comes from a study by Pennebaker and Skelton (1981), in
which some subjects were led to expect that exposure to ultrasonic
noise would increase their skin temperature, and other subjects expected their skin temperature to decrease. Subjects who expected an
increase reported attending more to sensations of increasing skin temperature and less to sensations of decreasing skin temperature than did
subjects who expected a decrease. Moreover, subjects interpreted their
temperature fluctuations in ways that were consistent with their hypotheses: for increase subjects, the more fluctuations they experienced,
the warmer they rated their skin temperature, and for decrease subjects,
the more fluctuations they experienced, the cooler they rated their skin
temperature.
Such model-driven or schema-driven processes of symptom interpre-
Causal Attributions in Health and Illness
197
tation are particularly interesting with respect to certain medical conditions, in which the experience of symptoms — or the lack of them — is
contrary to our usual models about the nature of disease. Despite being
told that hypertension is "silent," for example, patients often attribute
such symptoms as headache or nervousness to their hypertension. In a
study by Meyer, Leventhal, and Gutmann (1985), hypertensive patients
were found to monitor such symptoms and take their antihypertensive
medication according to when they noticed the symptoms, instead of at
thé regular intervals as prescribed. There also are other illnesses for
which the symptoms are not what one would expect for disease. Morris
and Kanouse (1979) give the example of hyperthyroidism, which brings
an increase in basal metabolism. Because increased energy is not typically associated with disease, this "symptom" may not prompt the patient to take action.
/. Motivational Influences on Symptom Interpretation. Although the
mechanisms of symptom interpretation have been described as primarily cognitive in nature, various motivations also may come into play.
Denial, for example, may occur when a person is threatened by the
possible meaning of symptoms (Cohen & Lazarus, 1979). Distortions in
symptom interpretation also may occur in the direction of making more
out of a symptom than is appropriate. Such effects may be generated not
only by personality influences (e.g., hypochondriacal or hysterical
characteristics) but also by self-presentational considerations. The analysis by Ε. E. Jones and colleagues (e.g., Jones & Berglas, 1978) of selfhandicapping suggests that a person may benefit from other people's
belief that he or she is ill. The others may take into account the person's
illness when evaluating task performances or other behaviors, thus
casting these acts in a more favorable light. (This effect may be understood through the augmentation principle.) A study by Smith, Snyder,
and Perkins (1983) indicated that hypochondriacal people report more
physical symptoms when they are likely to perform poorly and poor
health could be a plausible explanation for their performance. In medical sociology, the construct of secondary gain pertains to the related
question of whether a person adopts the sick role for the benefits of being
labeled as ill, such as being free of prior responsibilities in work or home
life (Gordon, 1966). We suggest that other people's attributions about the
causal basis of symptom reports or disability are determinants of
whether they assent to the person's adoption of the sick role.
2. Consequences of Symptom Interpretation
Once a symptom or syndrome of symptoms has been attributed to
illness, a variety of behaviors and other reactions may follow, depending
upon other beliefs, motivations, environmental supports or barriers,
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John L. Michela and Joanne V. Wood
and so forth. The following review of studies illustrates the kinds of
reactions that may be influenced by attributions of symptoms to illness.
a. Compliance with Medication Regimens. A consistent finding is
that only half of the patients for whom drugs are prescribed follow their
regimen (Sackett, 1976). The research by Meyer et al. (1985), described
earlier, suggests that one reason for medication noncompliance is that
patients may regulate their medication intake according to bodily signs
— a practice which is medically unsound for treatment of hypertension,
infection, and other ailments. Morris and Kanouse (1979) have described the attributional processes involved in this self-regulation process. Morris and Kanouse, like Leventhal, Meyer, and their associates,
posit a self-regulation model (see also Carver & Scheier, 1982), in which
patients monitor their physical sensations, compare them to an internal
standard, and use the result of the comparison as a basis for making
decisions. Morris and Kanouse (1979) offer the example of when a drug
is taken and the expected improvement does not occur. The patient may
then question whether the failure is due to the drug—is it ineffective, or
at an incorrect dosage level — or is the person's illness worse than he or
she had originally thought? The latter inference constitutes the "reverse placebo" effect, in which an absence of a therapeutic effect may
lead to worry about the seriousness of a disorder. Storms and Nisbett
(1970) found that when insomniacs were given a drug (actually a placebo) which they expected would improve their insomnia, their insomnia worsened instead. Presumably subjects had matched their symptoms (in this case, bodily arousal) to their expectations (that their
arousal would be gone), and concluded that their insomnia actually was
worse than they had thought (i.e., "augmenting" the perceived intensity of the disorder given the information that the "drug" had not reduced the insomnia). Although these results have failed to replicate
(Kellogg & Baron, 1975), more recent examinations have clarified some
of the reasons behind the failure to replicate and have generally supported the underlying attribution model of insomnia (Brockner & Swap,
1983; see Storms, Denney, McCaul, & Lowery, 1979, for a review).
Although knowledge of side effects of medications might be expected
to lead to poor compliance, research demonstrates that side effects may
be attributed to the potency of the medication, and hence the patient
may be more likely to believe that the drug is effective (for references
see Morris & Kanouse, 1979).
b. Pain. The wide variability that we noted earlier in individuals'
experience of pain under similar circumstances suggests that a host of
factors operates in pain, many of which may involve attributions. For
example, if a young boy feels sudden pressure on the body and attributes
this sensation to contact with a dangerous object, then he might experi-
Causal Attributions in Health and Illness
199
ence more pain than from pressure of equal intensity while playing
football.
Rodin (1978) reviewed experimental studies that are relevant to effects of attributions upon pain. Several of these studies used a "misattribution" paradigm, in which some subjects were led to attribute the
symptoms of a noxious stimulus (electric shock) instead to a placebo.
When these subjects were observed to tolerate more trials of exposure to
the shocks, it was suggested that their experience of pain had been
reduced by attributing fewer of their symptoms to the shocks. However,
Calvert-Boyanowsky and Leventhal (1975) have criticized the misattribution explanation of findings in several of these studies. The treatment
and control conditions confound attributions with accuracy of information about the symptoms that subjects are told they will experience.
c. Delay in Seeking Medical Care. Patients may delay in seeking
medical care while they are engaged in a search for an explanation for
their illness (Rodin, 1978). Total delay often is due largely to the length
of time it takes to interpret a symptom as caused by illness (Matthews et
al, 1983; Safer, Tharps, Jackson, & Leventhal, 1979). Matthews et αϊ.
(1983) studied myocardial infarction patients, and found that this first
stage of symptom interpretation was longer when symptoms were less
prominent and more ambiguous. For example, symptoms such as fatigue, upset stomach, and minor pains in areas other than the heart are
not usually thought of as symptoms of heart attack, and these were
associated with longer delays.
3. Patient-Physician
Differences in Symptom Interpretation
Attribution theory analyses (Jones & Nisbett, 1972; Ross, 1977) indicate that it is natural for health care practitioners to explain delay and
noncompliance in terms of factors residing within the patient, such as
ignorance or lack of motivation (cf. Rodin, 1978). We have had the
experience — in the supposedly enlightened 1980s — of speaking with
medical residents who make these attributions and are surprised to
learn that these behaviors may result from patients' inappropriate beliefs about causal processes, which could render this behavior rational
in its own frame of reference (see also Skelton & Pennebaker, 1982). We
recognize that information-processing mechanisms probably do not explain all delay or noncompliance. Denial and other seemingly irrational
processes may be commonplace. Also, interventions addressing environmental barriers have demonstrated effectiveness for increasing
compliance (Sackett, 1976). Nevertheless, the increasing depth of the
cognitive analysis of patient behavior appears promising for the development of educational and cognitive-behavioral strategies to increase
compliance and reduce delay. From the emerging perspective, people
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John L. Michela and Joanne V. Wood
actively seek the meaning of physical sensations and often are required
to make very difficult discriminations as to whether a sensation is
threatening or not. A decision to delay is not necessarily irrational or
inappropriate. "Hindsight is 2 0 - 2 0 , " but decisions about health-related
actions have uncertain consequences, including the possibility of feeling foolish or wasting time or money if a visit to the doctor reveals that a
sensation is not diagnostic of disease.
IV. ATTRIBUTIONS IN ADJUSTMENT TO ILLNESS
Serious illness presents a variety of threats, problems, or challenges to
individuals who become ill and to their loved ones (e.g., Burish &
Bradley, 1983; Cohen & Lazarus, 1979; Moos, 1977), including threats to
physical survival, to self-esteem, and to interpersonal relationships.
Cognitive, motivational, emotional, and interpersonal processes all may
be involved in the impacts of illness, so there are many possible roles for
attributions in adjustment to illness.
Our discussion will be divided again into sections on antecedents and
consequences of attributions. Occasionally this division is difficult to
maintain, because some of the same factors thought to instigate the
making of attributions are also thought to be consequences of attributions. For example, Kelley (1972a) suggested that a motivating force in
attribution processes is the attributer's need to maintain effective control over events. Attributions might serve this function by providing
information about how to act in response to a stressor or a victimizing
event. The empirical question on the antecedents side is whether variations in desire for control are associated with the making of attributions.
On the consequences side, the question is whether making attributions
leads to greater perceived or actual control, as well as to many other
possible outcomes in adjustment to illness.
A. Antecedents of Attributions for Illness or Injury
We have described the circumstances that have been found to prompt
causal attributions as including uncertainty and threat. Serious illness
certainly fits these descriptions. A woman who has just been informed
of her diagnosis of lung cancer, or a young victim of a diving accident
who will be paralyzed for life, provide clear illustrations.
There is ample evidence that seriously ill people form theories about
the causes of their illnesses (e.g., Bard & Dyk, 1956; Good & Good, 1980;
Koslowsky, Croog, & La Voie, 1978; Meyerowitz, 1980). For example, in a
study of breast cancer patients, Taylor et αϊ. (1984a) found that 95% of
Causal Attributions in Health and Illness
201
the patients had formed a causal theory. Slightly less than half of the
patients attributed their cancer to stress, which usually meant some
specific stressful event such as the death of a family member; about
one-third made attributions to a specific, perceived carcinogen, such as
birth control pills; about one-quarter to heredity; and 2 0 % or less to diet
or to a past blow to the breast. (The percentages exceeded 1 0 0 % because
some patients had theories involving two or more causes.) Several studies have indicated that MI (heart attack) is ascribed most frequently to
stress, worry, or tension, moderately frequently to one's physical condition (e.g., being overweight or inactive), and occasionally to "God's will"
or to fate (e.g., King, 1984; Koslowsky et αϊ., 1978).
One frequently studied attribution is self-blame. Many studies have
found a high degree of self-blame among victims (Abrams & Finesinger,
1953; Bard & Dyk, 1956; Bulman & Wortman, 1977; Chodoff, Friedman,
& Hamburg, 1964; Koslowsky et αϊ., 1978; Mastrovito, 1974). Bulman and
Wortman (1977), for example, studied quadriplegic and paraplegic victims of accidents, and found that over 6 0 % of the respondents ascribed
at least some responsibility to themselves, and that 3 5 % accepted at
least half of the responsibility. The specific content of self-blame attributions may include specific actions the victim took or failed to take
(e.g., eating too much, not relaxing enough), personality characteristics
(e.g., being a "tense" person), or guilt over past sins (see Janoff-Bulman &
Lang-Gunn, 1986, for a review).
1. Why Does Illness Induce Attribution Processes?
Janoff-Bulman and Frieze (1983) have proposed an overarching model
of responses to victimization that may explain several links of attributions to illness. Their model holds that much of the psychological distress of being a victim of a serious event (including rape, accidents, and
life-threatening illness) derives from the shattering of three basic assumptions: that the world is meaningful and comprehensible, that one is
invulnerable, and that the self is worthy of high esteem (cf. Perloff, 1983;
Scheppele & Bart, 1983; Silver & Wortman, 1980). The process of adjustment, then, may involve efforts to recover these basic assumptions, and
attributions may be part of these efforts (Janoff-Bulman & Frieze, 1983;
Taylor, 1983).
Regarding the first assumption, causal explanations may be made so
as to make the event seem less random and meaningless (Wortman,
1976). For example, attribution of a disabling accident to God's will may
provide a sense of order to the paralyzed victim. (Writers who refer to
finding "meaning" in an event sometimes appear to be dealing with the
search for compensatory benefits from an unpleasant event, which may
center on processes other than the causal analysis of the event.) Second,
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when a victim's assumption of invulnerability is contradicted by experience, a causal analysis may restore one's sense of control (Taylor, 1983;
Wortman, 1976). Attributions are seen as particularly likely to enhance
perceptions of control when the cause that is identified is modifiable,
and the victim thereby may prevent further victimization (Janoff-Bulman, 1979). Attributions have been linked less frequently to restoring
the third assumption listed above, i.e., the view of the self as positive.
Janoff-Bulman and Lang-Gunn (1986) have called attention to the
distinction between asking, "Why did this event happen?" and "Why
did this happen to me?" In answer to the first question, a victim may cite
known risk factors for an illness or known social causes of crime (e.g.,
poverty). The second question, which Janoff-Bulman and Lang-Gunn
(1986) have called the question of "selective incidence," concerns why
the particular victim was singled out for misfortune. It is possible that
the question "Why me?" is motivated more by concerns about justice, as
compared with the concerns about control that often are discussed in
relation to the question "Why?" a quotation from Zola, cited in JanoffBulman and Lang-Gunn, illustrates this point: "'Why me' . . . is generally expressed in quite moral terms of what [the victim] did wrong"
(Zola, 1972, p. 491).
Nevertheless, most discussions of victimization emphasize the need
for control as a motivator of attribution processes, and restoration of
perceived control as an outcome of attributions. However, neither the
need for control nor any other need or motive typically is tested empirically as an antecedent of attributions. In addition, in only a few instances has a presumed mediator between attributions and outcomes
been examined, and a restoration of control has not, to our knowledge,
been shown to occur as a result of attribution processes. Although obtaining such evidence would be difficult, evidence is important both
because of the presumed centrality of the need for control and because
there are plausible alternatives to a drive toward control as the central
instigator of attributions (e.g., concern for justice or meaning).
2. What Factors Determine the Particular Attribution Formed by an III
or Disabled Person?
a. "Reality." One factor that would seem to constrain the particular
attribution made would be the reality or factual bases of one's victimization. For example, victims of accidents in Bulman and Wortman's
(1977) study were more likely to blame another person if there had been
another person present at the time of their injury, because often this
person had some role in their accident, such as driving the car in which
they were riding, or cleaning the gun that accidentally shot them. However, the extent to which attributions may contradict "objective" ex-
Causal Attributions in Health and Illness
203
pectations can be surprising. Many of the people who had blamed themselves for their accidents had been seemingly innocent victims (Bulman
& Wortman, 1977). They had been accidentally shot, for example, or
were the passengers, not the drivers, of some ill-fated vehicle. Such
seemingly irrational attributions provide additional stimulus to attribution theorists to consider motivational antecedents of attributions.
b. Sociodemographic Factors. Although it seems quite plausible that
cultural and social factors would influence the causes that people identify for their illness, few sociodemographic factors have been demonstrated to be related to attributions. Koslowsky et αϊ. (1978), for example,
found that age, education, occupation, income, and religion did not
predict MI patients' attributions. In contrast, Tennen, Affleck, Allen,
McGrade, and Ratzan (1984) found that age was predictive: Older children were more likely than younger children to make external attributions. There is also some suggestion that religion may influence one's
attributions. Disabled people in Bulman and Wortman's (1977) study
were more likely to blame themselves if they were very religious. In
addition, there may be differences in types of attributions made by
members of different religions. Taylor, Lichtman, and Wood (1984b)
observed that, in comparison with other studies, there were relatively
few attributions to "God's will" in their disproportionately Jewish sample. Demographic associations involving age or religion may, of course,
turn out to be based on underlying factors such as cognitive development, models of illness, and so forth.
c. Sophistication/Prior Knowledge about the illness. Another factor
that is likely to influence one's attributions is sophistication about medical knowledge pertaining to the illness. Patients who themselves are
physicians, health psychologists, or otherwise connected with health
professions are likely to have causal theories that are relatively up-todate with the medical literature. Taylor (1982) points out that, in contrast, patients who are more naive adopt explanations for their cancer
that rely on simple attributional principles. One such principle is that
causes precede outcomes in fairly close temporal proximity (Michotte,
1963). Although cancers may grow for 15 years or more before they are
detectable, people unaware of this fact often assume that some recent
event caused the cancer. One woman in the Taylor et al. (1984b) study
believed that her cancer had been caused by a recent automobile accident. Another simple attributional principle of causality is that causes
resemble effects. People often assume that the size or importance of the
effect must reflect the size or importance of the cause. Cancer, a big
effect, is therefore attributed to a big cause. Patients who thought that
the cause of their cancer was stress rarely thought of that stress in terms
of the small, cumulative hassles of day-to-day life. Rather, they attrib-
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uted their cancer to some major source of stress, such as the death of a
loved one (Taylor, 1982).
Lay theories about causality may also derive from what amounts to
folklore or conventional wisdom. A fine example is the common attribution of MI to stress or tension (which may or may not turn out, with
futher biomedical or epidemiological research, to be veridical). The
cultural communication of this belief may be seen in a radio news report
in 1984, concerning a lawsuit brought by a decedent's family: A landlord
was alleged to have caused a tenant's fatal MI by harassing the tenant.
d. Comments. Few antecedents of attributions for illness have been
demonstrated. One important need for future research is to demonstrate
the influence of motives to control and understand the world. Effects
upon attributions from communications, including information taught
in patient education programs, also need examination.
We have not addressed the question of whether members of different
psychological classifications (as opposed to demographics) differ systematically in their attributions for illness. Present evidence on this
point is virtually nonexistent. Later our review will reveal some between-illness differences in attributions, and it is possible that such
differences arise not only from the influence of expert opinion about
causes of particular illnesses, but also by differences associated with the
types of persons most likely to contract particular illnesses. Specifically,
attributions to chance or luck are infrequent for heart attack but frequent for cancer. This difference in attributions coincides with a limited
body of evidence of differences in the kinds of persons most likely to
have heart attack (Type A individuals) or cancer (Type C individuals).
Type As (Friedman & Rosenman, 1981), who are activated by challenge,
might be expected to minimize the role of chance in their heart disease.
Type Cs (Temoshok & Heller, 1982), who are especially passive, might be
expected to emphasize chance in their attributions for cancer. To
uphold this highly speculative account it would be necessary to show
that the corresponding attributional tendencies do exist in Type As and
Cs, and that these groups' attributions diverge beyond whatever veridical basis there may be for different explanations of heart attack and
cancer.
B. Consequences for Adjustment to Illness
Do beliefs about the causes of one's illness have any impact upon
coping or adjustment to illness? One caveat arises immediately when
examining this question: Because the relevant studies are correlational,
the causal direction is ambiguous. Nevertheless, we will address the
Causal Attributions in Health and Illness
205
question as the literature poses it, taking the view that placing attributions before adjustment provides a useful heuristic for understanding
their relation.
1. The Construct of Adjustment
It is necessary first to analyze contemporary notions of coping and
adjustment. We agree with Silver and Wortman's (1980) view that in
most existing literature, coping is a heterogeneous construct, involving
a combination of responses that include cognitions (e.g., denial or acceptance), emotions (anxiety, depression, etc.), attitudes, and behaviors
(e.g., treatment compliance). We also agree that there is a more narrowly defined construct of coping concerned with active a n d / o r intentional responses directed toward controlling a stressor (e.g., Burish &
Bradley, 1983). Our use of the word coping will be restricted to the latter
meaning. For the larger concept involving various reactions to illness,
we will use the term adjustment. The heterogeneity of the construct of
adjustment suggests that the overall favorability of a person's adjustment may be impossible to evaluate, because a response may be beneficial for one domain of outcomes but detrimental for another domain. For
example, a patient's optimistic outlook might lead her to be relatively
free of unpleasant emotions but also to neglect her treatment regimen.
Reflecting the multifaceted nature of adjustment is the variety of
ways in which it has been operationalized. Some investigators have
examined the relationship between attributions and specific emotions,
such as depression, anger, and anxiety. Other investigators have employed an index thought to be an overall or summary measure of adjustment, formed by combining various measures of emotions, cognitions,
and behaviors. Still others have defined adjustment in terms of adaptive
behaviors, such as making health-related changes in lifestyle. (Studies
allowing separate examination of attributions in relation to behavioral
responses to illness were reviewed earlier, in Section III,A, because they
were interprétable through the attributional analysis of motivation presented in that section.) Measurement and conceptualization of adjustment have been complicated further by the frequent practice of obtaining data from various sources, usually including patients' self-reports
about adjustment outcomes but often adding ratings from health care
practitioners (e.g., Plotkin-Israel, 1984) and "significant others" such as
spouses. The use of non-self-report data is valuable for reducing threats
to validity (as when self-reports are both predictors and outcomes), but
disagreements between self- and other-reports do not necessarily stem
from invalidity of self-reports. Other persons' reports also are inferential
and subject to the errors and biases of attribution processes.
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2. Overarching Research Questions
a. Is Favorable Adjustment Promoted by Arriving at Some Causal
Explanation Rather Than None? As described earlier, the search for a
causal explanation is thought to be motivated by a desire for control
over the events in one's life (Heider, 1958; Kelley, 1967; Wortman, 1976).
A large volume of literature demonstrates that when people believe
they can exert control over some adverse event, they adjust more successfully (see Fiske & Taylor, 1984; Thompson, 1981). Thus, some attribution researchers have suggested that inasmuch as any causal explanation provides some degree of understanding and, therefore, potential
for control, persons who make attributions should be better adjusted
than those who do not.
Taylor et al.'s (1984b) study of breast cancer patients examined the
relationship between emotional adjustment and simply having an attribution. Emotional adjustment was operationalized as a factor score that
included the respondent's self-ratings of the specific emotions of anxiety, fear, depression, and anxiety; her overall rating of her adjustment;
and standardized measures: the Campbell, Converse, and Rodgers
(1976) Index of Weil-Being score, the Profile of Mood States (McNair &
Lorr, 1964), and physician and interviewers' ratings on the Global Adjustment to Illness Scale (Derogatis, 1975). Contrary to the view that any
attributions help the patient to feel better, the adjustment scores of
those who had no causal theory did not differ from those who had one.
Moreover, there are data to suggest that the making of causal attributions may be detrimental to adjustment. Silver and Wortman (1983)
interviewed approximately 100 people who had become physically disabled through an accident, and learned that those subjects who asked
themselves, "Why m e ? " 3 weeks following their injury reported more
depression, anxiety, and anger, and less happiness than those who had
not asked themselves this question. Of course, it may be that those
individuals who are most upset by their illness are those who are most
likely to search for an explanation for their illness. Silver and Wortman
(1983) speculate further that engaging in a causal search may reflect and
exacerbate endless rumination about the accident. Rather than dwell
on these ruminations, it may be more adaptive to focus on the coping
tasks that lie ahead (Silver, Boon, & Stones, 1983; Wortman, 1983). A
study of hemodialysis patients by Witenberg, Blanchard, Suis, Tennen,
McCoy, and McGoldrick (1983) suggests that the main issue is whether a
causal attribution is found if sought. Patients who had asked themselves
"Why m e ? " but had not found an answer were the most poorly adjusted.
These results support the initial suggestion that some attribution is better than none.
Causal Attributions in Health and Illness
207
Further research is needed to determine when an attributional search
constitutes an adaptive effort to regain control a n d / o r meaning and
when it becomes destructive. One determinant of the adaptiveness of a
causal search may be time since the onset of the illness or disability.
While speculating about the cause may be inevitable and even adaptive
at the beginning of the recovery process, continued rumination about it
months or years later may be maladaptive (Silver et αϊ., 1983; Wortman,
1983). However, Silver and Wortman's (1983) disabled subjects were
interviewed only 3 weeks after their accident, which would seem to fall
well within the range of time in which one would expect victims to
search for a causal explanation.
It is also important to repeat that the heightened emotions that these
victims reported should not necessarily be construed as poor adaptation. It is possible that those individuals who appear most upset initially
are those whose long-term adjustment is actually better. Derogatis,
Abeloff, and Melisaratos (1979), for example, found that cancer patients
who initially exhibited heightened emotions and a "fighting spirit" survived their illness longer than did those who initially were more calm
and accepting of their illness (see also Temoshok & Heller, 1982).
T h e literature does not now permit a conclusion about an overall
relation between attributions and adjustment. This question may be too
broad to yield any consistent answer.
b. What is the Relationship between Particular Attributions and Adjustment? Victims of illness may cite very specific events or conditions
as the cause of their illness, as illustrated by the specific physical injuries, stressors, or carcinogens reported in open-ended interviews of
breast cancer patients (Taylor et αϊ., 1984b). However, these workers
found no significant correlations between the global adjustment measure and specific attributions. Contradictory findings come from Michela's (1981) measures of husbands' and wives' attributions for the
husband's MI. Attributions and other variables were given the opportunity to enter stepwise regression equations in the prediction of anxiety,
depression, helplessness, and anger. One significant predictor of wives'
anger was their attribution of the MI to the husband's smoking.
T h e present research question and the immediately following question have received the largest amount of attention in the literature.
Therefore, after this preview of four questions, we will devote most of
the remainder of Section IV to a review of the relevant studies for
questions b and c.
c. How Are the Effects of Attributions upon Outcomes Mediated? According to the theoretical analysis offered in Section II, most relations of
specific attributions to outcomes are best understood by reference to the
meaning or implications of the cause. For example, the association of
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greater anger in wives with attributions to smoking (Michela, 1981) may
be understood by assuming that these wives blamed their husbands for
the MI, i.e., that their attributions to smoking meant that their husbands
were personally at fault. It was also suggested in Section II that the effect
of an attribution on an outcome is understood best by specifying how the
attribution fits into a more encompassing model of processes that govern
the outcome. For example, recent cognitive and attributional analyses
of emotion (see Epstein, 1984; Roseman, 1984; Rehm & O'Hara, 1979;
Weiner, 1982) indicate that the determinants of emotional reactions to
an event include the desirability or undesirability of the event and
cognitions about such matters as the legitimacy or future likelihood of
the event. Causal attributions may fit into the larger model because they
carry implications about matters such as the unfairness or likely continuation of an unpleasant experience. In our example, this reasoning
suggests that after the wives experienced many unpleasant consequences from their husbands' Mis (e.g., new responsibilities, worry),
anger resulted when the husband was seen as responsible for these
impositions. However, in this example and in the typical study, researchers have not directly measured the relevant mediators of emotions and other outcomes. Therefore our review of studies below often
will have to make assumptions about these mediators.
d. How Should Causal Attributions Be Measured? Essentially two
approaches have been used in the measurement of causal attributions
for illness. One is to ask about causality in an open-ended fashion, then
code the responses into the categories that emerge for the specific health
problem under study (e.g., Taylor et αϊ., 1984b). T h e other approach is to
present a list of possible causal factors, and obtain ratings of the extent of
causal influence from each factor. For example, Michela (1981) developed a list of possible causes on the basis of prior research (Koslowsky et
αϊ., 1978) and theoretical considerations (Kelley & Michela, 1980).
With either the open- or closed-ended approach, the researcher may
develop categories at various levels of specificity. At the most specific
level, kinds of foods eaten and elevated cholesterol might both be retained as possible factors to cite as causes; at the next higher level, only
diet-related factors might appear, as an aggregate of the two specific
causes. A potential problem in collecting data at higher levels of aggregation of causes is that each of the specific factors may have a different
meaning. For example, elevated cholesterol might be regarded as an
uncontrollable, physiological characteristic, while kinds of foods eaten
might be seen as controllable. Thus, if the outcome to be predicted from
attributions were mediated by perceived controllability, then diet-related factors would fail to predict the outcome — if some members of the
sample used this category with controllable, specific (diet-related)
Causal Attributions in Health and Illness
209
causes in mind while other people had uncontrollable specific causes in
mind.
Several investigators have dealt with this problem of specificity generality by, in effect, measuring attributions at an intermediate level
of specificity-generality, through use of the four causal categories of
sel/, other people, environment, and chance. These categories reflect the
internal-external distinction important to several theorists (including
Heider, 1958; Kelley, 1967), as well as the potential importance of distinctions between chance versus other environmental causes, and other
people versus other factors in the environment. These categories are
intermediate because effects of these causal categorizations are understood through invoking "higher order" mediational constructs, such as
control, capriciousness, malice, and so forth, that each category may
imply. "Below" any of these categories is the specific event or causal
condition that subjects have in mind when responding to the four categories. It will be seen later that some investigators have suggested dividing these categories into finer distinctions that correspond more closely
with presumed mediators of attributions.
Another approach to the problem of specificity-generality in measurement has been to measure attributions at a very specific level, then
use empirical methods to produce an aggregation scheme. For example,
Avis (1984) analyzed ratings of relatively specific causes of MI by multidimensional scaling (MDS) to establish their relations to one another
along dimensions such as internal-external. Koslowsky et αϊ. (1978)
used factor analysis for the same purpose, although their brief description of results suggested that causal perceptions were represented better
by categories than by dimensions. In various ways, the conceptual and
statistical model under which such analyses are conducted may have
substantial effects on results. (For descriptions of the use of factor analysis and MDS for grouping causal attributions, see Michela et αϊ., 1982;
and Weiner, 1979.)
e. Review of Studies. We turn next to studies that examine various
facets of the relationship between adjustment and attributions, organizing our review by the most frequently examined categories of
attributions — self, other people, environment, and chance. The first of
these categories is attributions of illness to the self, which are usually
called self-blame. However, we do not assume that attributions to the
self imply "blame" in the sense of moral failing (cf. Finchman & Jaspers,
1980).
3. Self-Blame: Adaptive or Maladaptive?
The literature contains a lively debate over the adaptiveness of selfattributions. On one side are researchers who suggest that self-blame
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may be harmful. Blaming oneself for having contracted a disease such as
cancer may make the patient feel inferior, ashamed, or guilty. Selfblame often is linked to depression more generally (Beck, 1976). If, in
contrast, one can blame an external source such as the environment,
one may be spared self-criticism and guilt.
On the other side of the debate, some researchers argue that selfblame is adaptive due to the sense of predictability or control that it
affords. Self-blame may have even greater adaptive effectiveness than
other forms of attribution for three reasons. First, as Janoff-Bulman and
Lang-Gunn (1986) suggest, self-blame may be the most satisfying answer
to the question, "Why me?" Unlike environmental or chance factors,
causal factors concerning the self may suggest more immediately why
one has been singled out for misfortune. Second, self-blame may promote a relatively satisfying sense of justice or fairness, in addition to
order. Third, self-blame may be particularly adaptive from the standpoint of control. As Wortman (1976) proposes, attributions to one's own
actions may imply that the victim has specific control over the course of
the illness (Wortman, 1976; Bulman & Wortman, 1977). A cardiac patient who believes that smoking caused the heart attack, for example,
may be very reassured by the decision to quit smoking. Where does the
weight of the evidence fall in this debate? Initially we will consider only
those studies that have looked for an overall effect of self-blame; studies
that distinguish between different types of self-blame will be covered
later.
Most of the research supporting the view that self-blame is harmful
consists of rather informal clinical observations (Abrams & Finesinger,
1953; Moses & Cividali, 1966; Weisman, 1975). Abrams and Finesinger
(1953), for example, interviewed 60 cancer patients, and concluded that
guilt arising from self-blame was a prevalent and destructive phenomenon among them. However, they do not report any specific questions
that they posed in the interview, nor how self-blame, guilt, or its adaptiveness were measured. A more rigorous study provides only limited
evidence; Witenberg et aJ. (1983) found a near-significant tendency for
self-blame to be associated with a measure of poor adjustment.
One prominent study supporting the view that self-blame is adaptive
is similarly informal in its observations. Chodoff et al. (1964) studied
parents of leukemic children, and argued that parents who blamed
themselves for their child's illness thereby avoided the more intolerable
conclusion that no one or nothing was to blame. One mother, for example, had concluded that her daughter had "caught" leukemia from their
ailing family pet, which the mother felt she should have removed from
the home.
More-structured observations also support the view that self-blame is
adaptive. The best known study in this area is Bulman and Wortman's
Causal Attributions in Health and Illness
211
(1977), which found that quadriplegic and paraplegic victims of accidents who blamed themselves for their accidents coped most successfully, as measured by social workers' and nurses' ratings of individuals'
acceptance of the reality of their injury and positive attitudes toward
physical therapy. Similarly, Silver and Wortman (1983) found that those
who blamed themselves for their spinal cord injury showed less distress
about their paralysis than those who blamed others. In addition, earlystage cervical cancer patients who attributed their disease to their "personality" or to "past behavior" reported less stress on a standardized
scale than those who attributed it to external factors (Gotay, 1981).
Finally, a composite measure of attributions, combining the causes personality and worry on the basis of a factor analysis, was negatively
associated with MI patients' self-reports of anxiety soon after MI (Michela, 1981).
Two studies indicate that, overall, self-blame is neither adaptive nor
maladaptive. Taylor et αϊ. (1984b) tested these competing predictions
regarding self-blame in their sample of breast cancer patients, and found
that self-blame was associated with neither good nor poor adjustment.
As reported in Section III, Plotkin-Israel's (1984) study of MI patients
found contradictory effects for self-blame upon recovery behaviors, depending on whether ratings of adjustment outcomes were provided by
nurses or patients. Plotkin-Israel also examined ratings of patients'
moods, hope and worry over the future, and depression. These outcomes bore no relation to self-blame in either nurses' or patients' own
ratings. Recent studies of victims of violence (Miller & Porter, 1983) and
parents of a chronically ill child (Affleck, Allen, Tennen, McGrade, &
Ratzan, 1985) have also failed to find a relation between self-blame and
adjustment.
One conclusion from these studies is that those who claim that selfblame is maladaptive have an obligation to support their claim with
firmer evidence. On the other hand, studies suggesting that self-blame is
adaptive also are few. Moreover, because few studies have been done, it
is impossible to identify patterns of results that would tell whether the
effects of self-blame depend on types of illnesses or other interacting
variables. However, the following literature suggests that a more finegrained analysis of types of self-blame may clarify matters.
4. Meanings of Self-Blame
For some patients or some illnesses, self-blame may signify control
and powerfulness, whereas in other instances, self-blame may signify
guilt and self-recrimination (Taylor et αϊ., 1984b). Distinctions between
these meanings of self-blame might be necessary before consistent effects of categories of self-blame may be observed.
a. Self-Blame for Cause versus Responsibility for Control. First, it is
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John L. Michela and Joanne V. Wood
useful to invoke Brickman, Rabinowitz, Karuza, Coates, Cohn, and Kidder's (1982) distinction between responsibility for causing a victimizing
event versus responsibility for controlling the victimization. We have
noted that self-blame for an illness may imply control over the future
course of the illness. However, the two attributions may be independent. A victim may blame herself for causing the illness and see no
solution; or a victim may exonerate herself of responsibility for the
cause, but nonetheless see herself as able to modify its course. For
example, a cancer patient may blame a nearby toxic dump site for her
cancer (external blame), and move to a new home (self-control). Or, she
may see her illness as punishment for past sins (self-blame), and see
herself as incapable of altering the course of her illness (external control). Thus, it is important to measure both self-blame and perceptions of
control and to determine their relationships to adjustment.
b. Behavioral versus Characterological Self-Blame. Janoff-Bulman
(1979) has distinguished two types of self-attributions that have different implications for controllability over one's future victimization. Behavioral self-blame involves attributing one's victimization to one's
specific behavior (e.g., "If I had stopped smoking, I would not have
developed heart disease"), whereas characterological self-blame involves attributions to one's character or personality (e.g., "I got heart
disease because I am a nervous person"). Behavioral self-blame, JanoffBulman (1979) suggests, often implies that one has control over future
victimization, because one may modify one's behavior. A woman with
high blood pressure who attributes her hypertension to taking birth
control pills may quit taking them and thereby feel in control of her
illness. In contrast, one's disposition is often seen as unmodifiable, and
characterological attributions may therefore cause one to lose hope.
Several studies support Janoff-Bulman's distinction between behavioral and characterological self-blame. In the only study of children's
attributions and adjustment to illness that we are aware of, Tennen et αϊ.
(1984) found that children who attributed their diabetes to some aspect
of their behavior (e.g., "drank too much soda") were rated as coping
better than those who made an external attribution (e.g., heredity).
Interestingly, no child in that study made a characterological attribution. Two studies not dealing with illness per se also support Janoff-Bulman's distinction. First, Janoff-Bulman (1979) found that although depressed and nondepressed women did not differ in their overall amount
of self-blame, depressed women engaged in more characterological selfblame than did nondepressed women. Similarly, Major, Mueller, and
Hildebrandt 's (1985) study of abortion patients suggested that those
women who blamed their pregnancy on their character did not cope as
well with the abortion as did low characterological self-blamers. In both
Causal Attributions in Health and Illness
213
Janoff-Bulman's (1979) and Major et al.'s (1985) studies, however, behavioral self-blame was unrelated to adjustment. This was also true of a
study of mothers of diabetic children (Affleck et αϊ., 1985).
A study by Timko and Janoff-Bulman (1985) is relevant to both of the
issues raised under the heading "Meanings of Self-Blame": (1) whether
adjustment is a function of attributions about cause or of beliefs about
control over disease recurrence, and (2) whether behavioral self-blame
has special benefits. These researchers developed a path model for their
data on various causal attributions, adjustment outcomes, and mediating cognitions in breast cancer patients. The path model was constrained a priori such that attributions about cause were exogenous
variables and had the opportunity to link with more general characterizations of causality (avoidability of incidence), with beliefs about control over cancer recurrence, with a measure of expectancy of avoiding
cancer recurrence, and with adjustment outcomes (measures of negative emotional states and self-esteem). Results revealed that behavioral
self-blame was not directly linked with adjustment outcomes; instead,
its effect was contingent on its meaning in the sense of whether it also
implied future avoidability of breast cancer. In the path model, behavioral self-blame was associated with future avoidability through a mediating variable, namely, whether the incidence of breast cancer had
been avoidable. The effect of future avoidability on adjustment also was
mediated by expectancy of avoiding cancer recurrence. In addition,
characterological self-blame was negatively associated with a different
mediator of expectancy of avoiding cancer recurrence, namely, perceived success of mastectomy.
In summary, Janoff-Bulman's (1979) distinction between behavioral
and characterological self-blame has proven to be useful. The small
body of evidence for the maladaptive nature of characterological selfblame shows a satisfying consistency. However, behavioral self-blame
appears sometimes to be adaptive, and sometimes to have no effect.
c. Meanings of Characterological Self-Blame.
Despite the evidence
to date, there are several reasons why characterological self-blame need
not be maladaptive in all instances. First, personality traits are not
always seen as unalterable. A cardiac patient who blames his disease on
his competitive, hard-driving personality, for example, may see himself
as capable of altering these traits.
Miller and Porter (1983) suggest a second reason why characterological attributions are not necessarily maladaptive: Dispositional factors
that one sees as responsible for victimization may be viewed positively
instead of negatively. Thus, if one attributes one's illness to qualities
that one likes or is even proud of, one's self-blame may not have a
self-recriminative implication.
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John L. Michela and Joanne V. Wood
d. How Critical Is Control? Earlier, we presented the case for the
adaptiveness of self-blame by listing a few of its potentially beneficial
meanings, including making one's victimization more comprehensible,
answering the question of "why m e ? , " and signifying control over one's
future victimization. However, it is this last meaning, control, that is
typically emphasized. This is true despite the fact that Bulman and
Wortman (1977), the researchers who first demonstrated the adaptive
possibility of self-blame, concluded:
It is our feeling that the data may be more indicative of a need for an orderly and
meaningful world than a need for a controllable one. (p. 362)
In their review of the self-blame literature, Janoff-Bulman and LangGunn (1986) identify several possible benefits of self-blame, but conclude by proposing that self-blame is adaptive when it enables a victim
to perceive himself or herself as invulnerable, i.e., as having control
over the future. However, there are two problems with an emphasis on
control as the mediator of self-blame. First, there is not yet enough
evidence to conclude that self-blame, even behavioral self-blame, affords a sense of control. Two studies suggest that it does and two suggest
that it does not. Plotkin-Israel (1984) learned that MI patients who made
controllable, self-attributions expressed greater feelings of control over
the future possibilities of a heart attack. Also, as described earlier,
Timko and Janoff-Bulman (1985) found that behavioral self-blame was
associated (indirectly) with perceptions of control over a cancer recurrence. However, Affleck et αϊ. (1985) found that behavioral self-blame
was uncorrelated with perceptions of control. Tennen et αϊ. (1984), who
found that behavioral self-blame was associated with good coping in
diabetic children, also found that attributions were not related to perceptions of control over health outcomes. This finding might be explained away if the measure of control actually was a very generalized
measure (like Rotter's I - E ) instead of a measure of control over one's
own illness. Nonetheless, if behavioral self-blame is mediated by only
certain types of perceptions of control, those types of control need to be
specified.
A second argument against the emphasis on control as responsible for
the adaptiveness of self-blame is that the issue of controllability may not
be equally important for all forms of victimization. Control over one's
future may be extremely important in the case of cancer or heart disease, for example, where the possibilities of recurrence loom large. In
contrast, this issue seems to be less important for victims of accidents,
for whom the extent of victimization is already determined. Thus, we
would agree with Janoff-Bulman and Lang-Gunn (1986) that self-blame
may influence perceptions of control, and that those perceptions of
Causal Attributions in Health and Illness
215
control may mediate adjustment, but we would argue that this relationship may be strong only for certain types of victimizations, namely,
those with a threat of recurrence.
It would follow from this reasoning that when self-blame is beneficial
due to its implications for controllability, its adaptiveness may change,
depending on the course of the illness. In the absence of a recurrence,
self-blame may improve one's spirits through the perceptions of control
that it has engendered. However, if a recurrence does take place, selfblame may then make the victim feel hopeless and helpless. Witenberg
et ai. (1983) found that patients who had taken some action to prevent
their kidney disease from progressing to the point of requiring hemodialysis, but who nonetheless required hemodialysis, were rated as coping
less well and as less compliant with their medical regimen.
5. Other-Blame
A majority of relevant studies suggests that blaming another person is
maladaptive. First, for Bulman and Wortman's (1977) accident victims,
blaming another person for one's disability was associated with poor
coping. Both Taylor et aJ. (1984b) and Timko and Janoff-Bulman (1985)
found that blaming another person was negatively associated with selfreports of emotional adjustment among breast cancer patients.
Several other studies of ill people's attributions, cited in earlier subsections, either did not measure "other-blame" attributions or had such
low frequencies of other-blame attributions that the absence of a relationship with adjustment does not challenge the findings here. However, some of the remaining studies reported detrimental effects of
other-blame in only a few of the instances where it might have been
observed in available data. For example, despite finding that wives who
attributed their husbands' Mis to his smoking were most angry after the
MI, Michela (1981) reported no effects of male MI patients' other-blame
(to wife or children) upon emotions or other adjustment outcomes.
Sense of Injustice as a Mediator. The others blamed by breast
cancer patients in Taylor et ai.'s (1984b) study typically were their physicians, for failing to give the right treatment at the right time, or their
husbands (or ex-husbands), for creating stress. Such attributions seem
quite likely to be accompanied by feelings of anger and resentment.
Similarly, in Bulman and Wortman's (1977) study, the others blamed
usually were another person involved in the accident, such as the driver
of the vehicle in which they were injured. Bulman and Wortman (1977)
proposed that the resentment associated with those attributions could
stem from concerns for justice:
Those who felt that another was responsible for the accident often remarked that it
was unfair that they had been hurt instead of the perpetrator. These results suggest
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John L. Michela and Joanne V. Wood
that when the circumstances of an accident seem particularly unjust, coping may be
difficult, (p. 361)
Further support for the possible mediational effect of a sense of injustice
is the finding that victims who scored highest on the Just World scale
reported themselves to be happier than the other victims did (Bulman &
Wortman, 1977).
Distress related to unfairness may arise from factors other than the
harmful acts of another person. In the Witenberg et αϊ. (1983) study,
cited earlier, patients coped most poorly if they had taken actions to
prevent kidney failure, but developed this disease nevertheless. However, this result raises an important issue that has been glossed over both
in this article and in some previous reviews. Victimization — and its
possible concomitant, sense of injustice—should not be defined solely
in terms of an outcome (serious illness, distress) but in terms of psychological experience that may occur under particular circumstances.
Some ill persons may not feel victimized if they believe that serious
illness is natural at some point in the life-span. Analysis and evidence on
these and related points are available in Deutsch (1985).
6. Environment and External Attributions
Although most studies of attributions in relation to adjustment include a category of attributions to the environment, and although respondents typically endorse this category to a moderate degree, specific
predictions or conclusions concerning environmental attributions receive little discussion. Traditionally in attribution theory, external or
environmental causes are conceived as opposite to internal or personal
ones. However, given the distinctions now made within self-blame, it
would be necessary to know which self-blame category should be considered opposite to external causes. T h e variety of possible meanings of
all the conceivable external attributions adds further complexity to the
needed analysis. Thus, it should not be surprising that most studies find
no relationship between environmental blame and adjustment, and
other studies are inconsistent. In the one study that did reveal a positive
relationship, mothers of diabetic children who attributed the child's
illness to the environment coped most successfully (Affleck et αϊ., 1985).
Two other studies, in contrast, indicated that patients who blame external causes cope poorly (Gotay, 1981; Tennen et αϊ., 1984).
7. Chance
Attributions of illness or injury to chance also receive very little
attention in the literature. This is quite surprising, given that chance
Causal Attributions in Health and Illness
217
was the most highly endorsed attribution in several studies (Bulman &
Wortman, 1977; Gotay, 1981; Taylor et αϊ., 1984b; Timko & Janoff-Bulman, 1985) and that attributions to chance seem to have implications for
each of the dimensions of meaning we have discussed — control, justice,
and comprehensibility. Particularly due to their inverse relation to control, chance attributions may, on the one hand, be expected to yield poor
adjustment. On the other hand, attributions to chance may spare one
the guilt, sense of (perpetrated) injustice, or low self-esteem associated
with other possible attributions.
In fact, no studies report a significant relationship between attributions to chance and adjustment. One possible reason for a lack of association is that the variance of chance attributions is so restricted (they are
so frequent for cancer and accidents, and so infrequent for MI) that it is
impossible to detect a covariation with other variables in the small
samples typically used. A second possibility is that chance is associated
with such diverse meanings that no single association with adjustment
exists.
8. Conclusion
Research has provided a great deal of information on the questions
posed about consequences of attributions. First, there is some preliminary evidence that when no causal explanation can be found, or during
long rumination about illness or injury, poor adjustment ensues. Second, several studies point to specific emotional consequences of particular attributions, such as depression with characterological self-blame,
and anger with other-blame. One of the more intriguing ideas in this
part of the field has been that one kind of self-blame—blaming one's
own past behaviors — has a salutary effect on emotional adjustment.
This effect may be due to the reassuring sense of control over the future
that behavioral self-blame may provide. Attributions to the environment or chance have not shown consistent relations with adjustment,
although these results may be due to the extreme frequency or infrequency of these ascriptions for the particular conditions examined to
date. Third, research on the mediators of effects of attributions is in its
infancy. Ideas about how attributions exert their effects pervade the
field and come into play in the design or interpretation of most studies,
but mediating variables usually have not been examined directly. This
criticism of health and illness research is similar to Kelley and Michela's
(1980) and Taylor's (1981) characterizations of most other attribution
research.
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V. IMPLICATIONS FOR THEORY, RESEARCH, AND
INTERVENTION
A. Theoretical Progress
Our review of studies pointed to several contributions of attributional
concepts toward understanding problems in health and illness. Preventive health and recovery behaviors were seen to be related to attributions that indicate one has the ability to perform beneficial behavior.
These findings were especially understandable in terms of more encompassing motivational models that employ attributions (e.g., Weiner,
1979) or other cognitions such as self-efficacy (Schunk & Carbonari,
1984) in explaining behavior. In the review of symptom interpretation,
many findings were consistent with current theoretical perspectives on
information processing and the making of attributions. In addition, selfregulation models (e.g., Carver & Scheier, 1982) provided a framework
for understanding how information about wellness or illness is selected
and used in approaching health goals. Finally, several aspects of emotional adjustment to illness were seen to be related to attributions in
various ways, and many of these findings were consistent with models
of cognitive mediation of emotion (e.g., Roseman, 1984).
Even though successes in attributional research were facilitated by
these encompassing models of motivation and emotion, we have suggested at several points that more specific evidence is needed that the
mediating processes postulated by these models do occur. The controversy surrounding the attributional mediation of effects of learned helplessness training (see Silver, Wortman, & Klos, 1982) shows that fundamental questions about mediators do not go away after elegant
theoretical formulations have been presented; fortunately these questions may persist until empirical evidence becomes convincing for the
mediational model. More specific evidence for the hypothesized mediator also may make more plausible the presumed causal direction, from
attributions to consequences. Moreover, a fuller examination of mediators of attributional impacts in the domain of health might promote
progress in the development of the models of motivation and emotion
that are used frequently in health, social, and clinical psychology. Such
a contribution to progress at the more global level would "close the
loop" that extends, ideally, from theory to application and back to
theory.
The correlational nature of the research on attributions in health does
not permit a firm conclusion that attributions cause behavioral or emo-
Causal Attributions in Health and Illness
219
tional consequences, i.e., that attributions develop prior in time to
behaviors or emotions and that no third variable could account for the
observed associations. Indeed, it also seems plausible that emotions,
motivations, and behaviors influence attributions in some circumstances. However, the existence of bidirectional causality would not
necessarily challenge the theoretical or practical significance of past
research that has considered attributions to precede motivation and
emotion. Some studies of health or illness have used designs consistent
with the latter causal logic, as in prediction of recovery behaviors from
attribution ratings obtained earlier in time (Plotkin-Israel, 1984). Also,
from outside the field of health there are data from true experiments in
support of the causal influence of attributions, e.g., a magnifying effect
of internal attributions on pleasant and unpleasant emotions (McFarland & Ross, 1982). In addition, relatively powerful correlational designs
such as cross-lagged panel analysis have provided evidence of the temporal precedence of attributions in motivation (Rest, 1976). Thus it
seems likely that attributions influence motivation and emotion in
many health and illness contexts.
A separate issue pertaining to mediation of attributional effects is
whether attributions should be considered unimportant when more
immediately mediating variables in motivation and emotion have been
identified. For example, in a study outside the health domain, Fincham
and O'Leary (1983) presented evidence that the effects of attributions
upon interpersonal responses to a spouse's pleasing or undesirable acts
are mediated by the feelings engendered by those acts. In a causal path
model, attributions predicted the strength of positive or negative feelings, and these feelings predicted interpersonal responses; these was no
additional effect of attributions on interpersonal responses after feelings
entered the prediction of interpersonal responses. Fincham and O'Leary
suggested that the absence of a direct effect of attributions on responses
made attributions "superfluous" (p. 54). We would argue instead that if
some behavior is of interest, and feelings influence the behavior, the
influences on feelings (i.e., attributions) are also of interest. Or, as an
example from the health domain, as more evidence is obtained of the
impact of self-efficacy on health behaviors, it may still be of interest to
study how attribution processes influence the extent of self-efficacy.
The literature on attributions and health generally lacks empirical
studies of the important area of interpersonal consequences of attributions (e.g., corresponding to the F i n c h a m and O'Leary study cited
above). T h e experience of illness may produce a variety of interpersonal
stresses, and attributions could have significant ameliorating or exacerbating effects in this arena.
John L. Michela and Joanne V. Wood
220
B. Possible Directions for Research Methods
1. Mediation Analysis
There are several approaches available for gaining evidence of the
mediators in naturalistic studies of attributions. In one approach, investigators have identified circumscribed dimensions of meaning implied
by attributions, e.g., "was it something about my behavior or myself as a
person that brought about my illness?" (Janoff-Bulman, 1979). Then
measures of causal beliefs have been worded to correspond with these
dimensions. Subsequent findings of associations between attributions
and outcomes (e.g., depression) are readily interpreted as a consequence of the specific aspects of causality differentiated by the circumscribed measures.
Another approach is to obtain ratings of the extent of causal influence
upon an outcome from each of many possible causes of an event, along
with ratings of the degree to which each cause is perceived to have
implications (meanings) that might mediate the influence of the causal
perception on the outcome. These implications may concern controllability, sense of injustice, future outcome expectancies, and so forth.
Statistical analyses then may be designed to demonstrate that one of
these meanings mediates the effect of the specific attributions on the
outcome under examination. In structural equation modeling (Bentler,
1980) it is possible to estimate simultaneously the causal influences of
the mediating cognitions upon the outcome, as well as the influences of
the specific attributions upon how strongly the mediating cognitions are
held. The major example of this kind of analysis in the health or illness
literature is in Timko and Janoff-Bulman (1985), described in Section IV.
Other examples using similar methods are available in related literatures (e.g., on intrinsic motivation; see Harackiewicz & Manderlink,
1984). However, the examination of mediators need not be based on
complex statistical methods to be useful — at least for hypothesis
generation — as shown by Lenker, Loring, and Gallagher (1984). These
researchers had been surprised to find that health outcomes were not
mediated by performance of recovery behaviors that had been taught to
a group of arthritis patients. Follow-up interviews with the study participants involved a combination of closed- and open-ended questions
about patients' feelings, beliefs, and motivations, during and after the
training program. Results indicated that patients who believed they
could control their arthritis symptoms also reported less pain or disability, or fewer arthritis-related physician visits.
Causal Attributions in Health and Illness
221
2. More Re/ined Measures of Attributions and Adjustment
One seemingly subtle issue in measurement is whether terms such as
cause, reason, blame, and so forth mean the same thing to respondents as
to researchers (cf. Fincham & Jaspars, 1980). Work on the distinction
between causes and reasons (the latter relating to intentional acts) provides one basis for this concern (see Harvey & Weary, 1984, for references). Thus, in the area of health behavior, the term causes might be
inappropriate when people analyze why they fail to take health actions
that seem at least partially under volitional control. In the area of illness,
the term blame has been used with respondents, even though its moral
implications and other possible meanings are unaddressed in research.
A striking example of the effects of exactly how attributions are probed
appears in Bulman and Wortman's (1977) study of accident victims.
Respondents who "blamed" themselves for their accidents often answered "no" to a question about whether the accident could have been
avoided, and only rarely did these self-blamers think they "deserved"
the accident.
A potential hazard in the future development of the field may lie in
the way coping and adjustment have been conceptualized and thus
measured in several studies. On the one hand, it might appear that
various emotions, attitudes, or behaviors should be combined into a
single index when such a composite is meaningful to raters or has been
derived statistically (e.g., by factor analysis). On the other hand, even
when these aspects of adjustment correlate substantially with one another, each aspect may be predicted best by different attributions or
other antecedent variables (Cohen, 1976; Michela, 1981). Such findings
challenge the utility of global constructs of coping or adjustment, especially for theoretical purposes such as determining whether particular
meanings of attributions have particular consequences. There may well
be some practical or theoretical purposes for which the global conceptualizations are most useful, but these should be demonstrated (cf. Watson & Kendall, 1983). Another concern is whether the favorability of
coping and adjustment is judged differently by different observers (e.g.,
practitioners versus patients) and why this might be so.
3. True Experiments
The extent of knowledge about attributions and their mediators may
someday permit the design of true experiments in health care settings.
We can imagine, for example, research in which various attributions are
induced in patient education programs. Mediation analysis would still
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John L. Michela and Joanne V. Wood
be valuable, but random assignment and the experimenter's delivery of
treatments would help to establish the direction of causal influence.
Such research would be analogous to the studies of the effect of personal
control interventions with the institutionalized elderly, by Rodin and
Langer (1977) and Schulz and Hanusa (1978). The latter study also raises
the question of when it is ethical to conduct field experiments. Schulz
and Hanusa (1978) presented evidence that long-term outcomes in their
experimental group were worse than in the control group, after a personal control intervention was delivered and later terminated. These
researchers subsequently considered several possible ways of avoiding
detrimental effects in such studies, basing their suggestions on attributional analysis of the treatments in their own research compared with
that of Rodin and Langer (1977).
C. Applications to Health Interventions
The evidence for impacts of attributions on motivation and emotion
suggests that if particular attributions could be induced in health interventions, then desired motivational or emotional effects of intervention
programs would be enhanced. For example, mass media interventions
to promote more healthful food choices might provide attributionally
relevant information, e.g., about the causal impact of food choices on
health and the causal efficacy of individuals to obtain and prepare foods
in ways that enhance health. A rather different application might involve a clinical psychologist's intervention to reduce the distress of
chronic illness. The clinician might probe the client's causal beliefs
about etiology or recovery, and support those beliefs that would, according to attribution theory and research, reduce distress.
1. Issues in Therapeutic Applications of Attribution Theory
There are several issues, however, that arise immediately for this
analysis of applications.
a. Present Knowledge Is Incomplete.
Common-sense ideas about the
effects of specific attributions may be wrong often enough to warrant
constant scrutiny. The preceding discussion of long-term effects of control interventions (Schulz & Hanusa, 1978) provides one illustration. As
another example, it would seem reasonable to focus therapy upon an ill
person's self-blame, given its importance in theories and research on
depression (see Abramson, Garber, & Seligman, 1980, for a review; see
also Abramson et al., 1978; Beck, 1967). However, Janoff-Bulman's
(1979) work points to a type of self-blame — behavioral self-blame —
that has not been considered in these models and that is not positively
associated with depression. Self-blame appears to have several mean-
Causal Attributions in Health and Illness
223
ings, and its potential for good or poor emotional adjustment depends on
the consequences of those meanings. We also have suggested that selfblame may be especially maladaptive when control is not possible, such
as when illness has recurred despite one's preventive efforts (cf. Witenberg et αϊ., 1983). Thus, the practice of targeting interventions on the
basis of intuitive assumptions must be supplanted by empirically based
identification of maladaptive cognitions. Moreover, this empirical basis
must be very specific as to the particular context in which that cognition
occurs.
What is today's clinician to do, until such evidence accumulates? We
advise clinicians to be very cautious, to consider and probe the possible
meanings of a particular attribution for the individual in treatment, and
to look for associated cognitions and behaviors that give clues to the
adaptiveness of a client's attribution. We will return to this issue in the
discussion of cognitive-behavioral therapy.
b. Attributions Already Are Used, Implicitly, in Interventions.
Re-
turning to the example of a mass media program to encourage preventive health behaviors, it seems likely that most any program would
include information about causal impacts of behavior on health. (We
recently saw a brief public service announcement on television that
contained the verbatim message "Smoking causes cancer".) Also, some
existing clinical procedures are designed to influence attributions, as
when clients are induced to view behavior change as the result of their
own efforts (Turk & Speers, 1983). What might an explicitly attributional
analysis contribute to health interventions? First, it would provide a
clear focus for intervention efforts. For example, if the therapist conceptualizes maintenance of behavior change as partly an attributional
problem, he or she might work with the client to find supporting evidence for the influence of personally controllable factors over the behavior. The therapist might also attempt to structure the client's causal
beliefs in ways that minimize the impact of initial failures to maintain
the behavior change, so as to avoid total relapse to prior behaviors (cf.
Marlatt & Gordon, 1985). The best attributions for avoiding relapse may
be to unstable factors and, perhaps, external or specific (as opposed to
global) ones, though evidence is needed. A second reason to make attributions more prominent in therapy is that attributions often may be
more alterable through psychoeducational practice than many other
determinants of behavior or emotion, because attributions are beliefs
(rather than personality characteristics, personal values, and so forth).
Moreover, the many antecedent processes identified for attributions (as
sketched in Section II) should provide many ways to influence attributions in interventions, ranging from use of primitive principles of attribution (e.g., similarity) to multifactor covariation analysis. Discussions
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John L. Michela and Joanne V. Wood
and illustrations of attribution change procedures are available in Berley and Jacobson (1984) and Sober-Ain and Kidd (1984).
c. Attributions Are neither Necessary nor Sufficient Determinants of
Much Behavior or Emotion. The encompassing models of motivation
and emotion discussed throughout this article point to factors that often
operate along with attributions to produce outcomes. Thus, we expect
that practical interventions directed solely at attributions would not
succeed for many behaviors or emotions. Treatment approaches that
draw upon attributional concepts also should deal with other facets of
the problem at hand, such as values, knowledge, environmental factors,
interpersonal interactions, and so forth. For example, cognitive behavioral treatments for health-related problems (see Bradley & Kay,
1985; Kendall & Turk, 1984) have multiple components, some of which
address dysfunctional beliefs (which may include attributions) while
others deal with skills training or other concerns. Obviously there may
be many health or illness problems for which attributions need not be
considered at all in effective treatments. As with other theories, part of
the challenge in applying attribution theory effectively is to find the
circumstances in which its use has special value.
d. An Attribution That Would Promote a Desired Motivational or Emo-
tional Consequence May Not Be Plausible or Truthful.
The question of
whether inaccurate attributions should be induced has been raised at
least since Valins and Nisbett's (1972) early analysis of attribution in
treatment of emotional disorders. In addition to the thorny ethical problems here, there is a practical problem that the public would be likely to
learn about widespread legerdemain in attributional inductions. Speaking optimistically, these problems may not be so acute if the multiplicity
of meanings of attributions and other cognitions somehow can be managed by the treating professional in a way that facilitates beneficial
causal inferences.
2. Implications for Cognitive-Behavioral Therapy
The results of studies on the relationship between attributions and
adjustment to illness clearly indicate that some assumptions underlying
cognitive-behavioral therapy (CBT) need review. Specifically, CBT frequently has been based on ideas about the cognitions that are associated
with particular outcomes, and hence, which cognitions should be the
target of therapy. As discussed above, such assumptions are hazardous
and must be verified empirically.
Our emphasis on the multiple meanings of attributions points to a
second implication for CBT. At times, CBT is presented rather simplistically: if a cognition can be changed, behavioral or emotional change will
follow. We take issue with this view on two counts. First, maladaptive
Causal Attributions in Health and Illness
225
cognitions have been conceptualized as though they are discrete and
isolable from other cognitions. A demon cognition can be stalked, exorcised, and then replaced with a healthier one. However, when the offending cognition is viewed as richly connected with other cognitions in
schemata, having been formed through information-processing mechanisms discussed in Section II, its removal and replacement becomes
much more complicated. Recent attempts at integrating cognitive and
social cognitive research with CBT present similar views (Hollon &
Garber, 1986; Winfrey & Goldfried, 1986).
The second point with which we take issue involves the one-to-one
linkages sometimes implied as existing between specific cognitions and
behavior. Attributions appear to have variable meanings that mediate
their consequences. For example, when self-blame implies high perceptions of control, this may motivate the attributer to lead a healthier
life, whereas low perceptions of control (e.g., with characterological
attributions) may discourage attempts at lifestyle change. Thus, in order
to develop a cognitive-behavioral intervention, it may be necessary to
understand a client's beliefs at a deeper level than some CBT writings
imply.
Further elaboration of the way attributions and other cognitions are
conceptualized in CBT may be warranted by other distinctions and
constructs that seemed useful in this article. It appeared not only that a
single attribution may be linked with different meanings for different
persons, but also that the full meaning of a given person's attribution
may require several dimensions to describe (e.g., internality, stability).
The latter reasoning may be reversed, to suggest that a given meaning
may be linked with, or expressable by, multiple attributions or other
cognitions. Taylor (1983) has suggested that when cognitions are formed
in order to satisfy motives or perform other psychological functions,
they may be substitutable with other congitions that also serve the same
functions. For example, the motive for control may be served through
making an attribution for the cause of one's illness, or through perceptions of control over the future course of the illness, and it may be
arbitrary whether one or the other cognition is present. Taylor (1983)
observed, for example, that some breast cancer patients whose perceptions of control were disconfirmed through a recurrence appeared to
restore control by shifting their attention to other aspects of their lives
that were controllable (e.g., taking up a new hobby). Changing a cognition, then, would not necessarily affect the function it serves, and this
function may then be expressed through some other cognition.
The Locus o/intervention. The emphasis on mediators in this article
suggests that interventions aimed at behavior or emotion might be directed at their mediators instead of the antecedent attributions. Hollon
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John L. Michela and Joanne V. Wood
and Garber (1980,1986) have offered the same suggestion in a discussion
of treatment for depression. While they concur with attributional
models as to the etiology of depression, Hollon and Garber argue that the
most effective targets of intervention need not be isomorphic with the
original etiological factors. As an example, Hollon and Garber emphasized the mediating role of pessimistic expectancies in maintaining depression. Once an attribution has been formed that implies persistence
of poor outcomes in the future, an exacerbation cycle may be established. In this cycle, poor outcomes maintain the expectancy, and the
expectancy interferes with the motivation so as to render poor outcomes
more likely. Thus, the optimal point of intervention might be within this
cycle rather than toward the attribution that initiated the cycle.
Hollon and Garber (1980) go further to suggest that expectancies generally are more effective targets of intervention than attributions (cf.
Bandura, 1977). Their argument rests on two points. First, they hold that
an attribution must be translated into an expectancy in order to have an
effect on behavior. For example, if a man attributes a failed romantic
relationship to his unexciting personality, this could represent an attribution to an internal, stable, and global factor. Because of the temporal
stability of the attribution, the person also expects that future relationships will be unsatisfactory. These negative expectations lead the person to avoid meeting another person and beginning a new relationship.
Hollon and Garber's second point is that because expectations mediate
behavior, only they can be put to empirical test. In keeping with CBT's
emphasis on collaborative empiricism, which stresses the superiority of
empirical testing over verbal persuasion, they question the usefulness of
trying to change attributions directly. They argue that alterations of
attributions per se are limited to post hoc discussions with the client
about the validity of an attribution. Nevertheless, if a man's attribution
"I am a boring person" leads to the negative expectation, "No one will
talk to me at a party," then the expectation can be tested in behavioral
interaction. If the person goes to a party and has a good time, the negative
expectation is disconfirmed. Of course, a great deal of effort may be
necessary to ensure that the expectation is disconfirmed (e.g., social
skills training).
In sum, viewing attributions as the source of poor adjustment to illness does not necessarily imply that the goal of therapy should be to
teach clients to be accurate causal analysts. In some instances, interventions might be most effective if mediators such as expectations or
perceived control instead are targets of CBT interventions.
A final implication of this article for CBT also stems from its emphasis
on mediators. If behavior change is effected by interventions aimed at
the mediators, the original attributions also may change. After seeing
Causal Attributions in Health and Illness
227
his expectations for being a wallflower at parties consistently disconfirmed, our client's original attribution, "I am a boring person," is weakened. Indeed, the new attribution may, in time, strengthen the expectancy as the two cognitions become consistent with one another. We can
imagine dysfunctional attributions about one's ability to perform aerobic exercise or to cope with serious illness undergoing similar change
through the impacts of behavioral enactments upon mediators of attributions. However, a more complete account of such dynamic relations
between outcomes, mediators, and attributions would require models
more complex than any yet devised.
ACKNOWLEDGMENTS
We are very grateful to the following persons who thoughtfully read and commented
upon an earlier version of this article: Laurence Bradley, Morton Deutsch, Barry Färber,
Connie Hammen, John Harvey, Ronnie Janoff-Bulman, Tracey Revenson, Richard Sloan,
Shelley Taylor, Howard Tennen, Suzanne Thompson, Dennis Turk, and Gerdi Weidner.
Work on this review was partially supported by a grant to J. L. M. from the Spencer
Foundation.
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Cognitive-Behavioral Perspectives
on the Assessment and Treatment
of Child Abuse
SANDRA T. AZAR
Department of Psychology
Clark University
Worcester, Massachusetts 01610
CRAIG T. TWENTYMAN
Department of Psychology
University of Hawaii
Honolulu, Hawaii 96822
I. Introduction
II. A Cognitive-Behavioral Approach to
Child Maltreatment
A. The Parent
B. The Child
III. Cognitive-Behavioral Assessment in Child Abuse . . .
A. Assessment of the Parent and Family Interaction .
B. Assessment of the Child
IV. Intervention
A. Intervention with the Parent
B. Intervention with the Child
V. Summary
References
237
241
241
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250
251
253
255
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259
260
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I. INTRODUCTION
Child abuse has only relatively recently come to the attention of the
behavioral scientist, and inclusion of this article might, therefore, seem
premature. Yet, the field of child maltreatment is an area in which
behavioral research has begun to appear with increasing frequency. The
problem is widespread, and represents a medical, psychological, and
237
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AND THERAPY, VOLUME 5
Copyright © 1986 by Academic Press, Inc.
All rights of reproduction in any form reserved.
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Sandra T. Azar and Craig T. Twentyman
social problem of considerable significance. Estimates of incidence in
the United States vary widely, but even conservative estimates place
the rate of abuse at greater than a quarter of a million cases per year. This
figure would be even larger if one included neglect, which is likely to
occur at an even higher frequency. Epidemiological rates also may represent an underestimate, given some reluctance on the part of authorities to report cases and the fact that many cases may simply go unnoticed. There is evidence that the number of child abuse cases may be on
the upswing (Barahal, Waterman, & Martin, 1981), although this may be
due to greater public awareness of the problem and the legislation of
mandatory reporting laws. In any case, child abuse clearly is a social
problem that significantly and directly affects the lives of a large number of families.
In addition to the widespread occurrence of child abuse, there is the
question of its costs to society. Considerable portions of state and federal
allocations are directed toward providing foster care services (Fanshel &
Shinn, 1972) and other ancillary support services such as child care,
counseling, medical care, and mandated social services (Newberger &
Hyde, 1979). Beyond the monetary costs of such programs, however, are
the consequences to both the children and parents on which it is impossible to place a value. The child suffers not only physical damage, but
also psychological and developmental deficits (Sroufe & Egeland, 1981;
Martin, 1976), and parents must also deal with the psychological stress
of having abused a child and of being identified by society as cruel or
inadequate parents.
Although child maltreatment is a serious problem with long-term
psychological and physical sequelae, it has received little attention by
behavioral scientists. There are a number of reasons for this. First, prior
to 1970 the emphasis of persons working in this area was on documenting the physical consequences of abuse and establishing a legal system
to handle the problem. Initially, workers in the area were primarily
physicians and lawyers. As a consequence, child abuse was conceptualized as either a disease or a crime, rather than as a dysfunctional pattern
of family interaction or as a result of behavioral deficits in the parent. As
a result of this early medical orientation, behavioral scientists largely
overlooked the area.
Further, the earliest psychological theories of etiology were psychodynamic, which did little to encourage the systematic collection of data
on the perpetrator's or victim's behavioral repertoire. Rather, these
theories centered on the presence of psychosis in the parent or on internal dynamic conflict. This lack of empirical emphasis is apparent in the
literature that has been amassed in the area. One review of 270 articles
dealing with etiology (Plotkin, Azar, Twentyman, & Perri, 1981) found
Assessment and Treatment of Child Abuse
239
that only 2 5 % were based on empirical data and the majority of these
relied on clinical impression or archival data. Thus, the early psychological theories did little to provide a solid foundation of descriptive information from which behavioral work could begin.
Another factor which inhibited interest by behavioral scientists is
inherent in the nature of child abuse itself. That is, an operational
definition of child abuse in behavioral terms is difficult to outline. Because direct observation of abusive acts is rarely possible, many definitions have centered on documentable consequences to the child rather
than on the parent's or the child's actual behavior. Moreover, alternative efforts at definition have clouded the issue further by including a
criteria of intentionality. Gil's (1970) statement is an example of this type
of definition:
Physical abuse of children is the intentional, nonaccidental use of force, on the part of
the parent or other caretaker interacting with a child in his care aimed at hurting,
injuring, or destroying that child. (Gil, 1970, p. 6)
It is interesting to note that definitions based on either consequences or
judgments of intentionality have been shown to be biased (Newberger,
Reed, Daniel, Hyde, & Kotelchuck, 1977; Turbett & OToole, 1980). Many
of the present definitional approaches are, therefore, troublesome to
behaviorally oriented research, which requires clear and operationally
defined behavior for classifying subject populations and to determine
baseline data in intervention programs.
Despite these obstacles, a number of factors have begun to encourage
the growth of behavioral research. First, there has been a move away
from models emphasizing parental psychopathology. It has been found,
for example, that only a small percentage of abusing parents suffer from
psychosis or severe personality disturbance (Steele, 1975). Researchers,
therefore, are now concerned with discovering interactional characteristics which differentiate maltreating families from comparison families.
Second, behavioral approaches which are typically characterized by
methodological rigor are seen as a valuable addition to child abuse
work, which has been plagued by poor experimental designs and an
inadequate data base (Plotkin et aJ., 1981). Problems have included lack
of control groups, failure to match samples on important demographic
characteristics, and data sources which are unreliable or incomplete
(e.g., clinical impression or archival data).
A third factor which has encouraged behavioral exploration in the
area of treatment programs has been the legal system. Increases in the
reporting of abuse have come with mandatory reporting laws. Coupled
with these increases has been a more recent emphasis in the court
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Sandra T. Azar and Craig T. Twentyman
system on maintaining the family unit. One reason for this may be
findings indicating the high cost and negative impact on children of
foster care placement (Schor, 1982). In any case, family-oriented courts
have increased the pressure on psychologists and social service agencies
to intervene effectively with these problematic families to ensure the
safety of the child.
To date, traditional intervention programs have not been effective
with abusing families. Many clinical reports claim effectiveness (Kempe
& Heifer, 1972; Pollock & Steele, 1972; Lynch & Ounsted, 1976; Green,
1973,1976; Blumberg, 1974), but these have not been done with systematic evaluation data in hand. In marked contrast to these clinical reports,
results of a nationwide evaluation of 11 demonstration programs indicate a poor success rate (Cohn, 1977). Of the 1024 treated individuals,
3 0 % severely reabused or reneglected their children while participating
in the programs. Less than one-half were judged by their therapist to
have reduced potential for abuse. While there are methodological problems in lumping together samples from different programs, questions
are raised about the efficacy of present intervention programs with
maltreating parents.
Behavioral treatment techniques are particularly attractive for use
with abusers. First, there is evidence that a large number of the abusing
population tend to be found among the lower socioeconomic classes
(Parke & Collmer, 1975), and behavioral techniques which are more
concrete and action oriented may be more acceptable to this group
(Lorion, 1978). Second, abusers are frequently involuntary or reluctant
clients and resistance to treatment is a common occurrence. Behavioral
interventions, as opposed to insight-oriented therapies, can be presented in "educational" formats which may lessen resistance. Thus,
parents can perceive themselves attending "parenting classes" rather
than going to psychotherapy sessions which may be identified with
"being crazy." A third positive aspect of behavioral intervention is that
effective techniques already exist for modifying parental behavior.
There is, for example, a large literature on the use of behavioral techniques to modify the behavior of parents of disordered children (e.g.,
Graziano, 1977). This literature could readily be adapted to the needs of
abusing parents.
A cognitive - behavioral approach to the problem of child abuse seems
to hold considerable promise. This article will explore cognitivebehavioral approaches to the assessment and treatment of abusive parents and their children based on the current literature. Because behaviorally and cognitive-behaviorally oriented programs in this area are a
relatively new occurrence, this article will present views that are somewhat speculative and conclusions that are still tentative.
Assessment and Treatment of Child Abuse
241
II. A COGNITIVE-BEHAVIORAL APPROACH TO
CHILD MALTREATMENT
The first step in utilizing behavioral techniques with maltreating
families requires the conceptualization that child abuse results from a
set of behavioral and cognitive dysfunctions. Since only one prospective
study has been conducted (Sroufe & Egeland, 1981), it is difficult to
determine whether parental and child deficits are causally related to
maltreatment or are a result of the abusive incident. Nevertheless, correlational data do exist linking certain characteristics to child abuse.
A. The Parent
The existing work in child abuse suggests that abusing parents have
deficits in the following areas: (1) ability to cope with stress, (2) relevant
social skills, (3) parenting skills, (4) cognitive dysfunctions, and (5) impulse control. Since no single characteristic has been shown to distinguish every abusing parent from others (Parke & Collmer, 1975; Gelles,
1973), it may be that any individual abuser might have deficits in only
one or a subset of these areas.
1. The Ability to Cope with Stress
The evidence for a deficit in the ability to cope with stress is largely
indirect in nature. That is, there is some demographic and self-report
evidence that abusers are exposed more frequently to stressful situations (Justice & Justice, 1976), are more likely to be unemployed (Galdston, 1965; Young, 1964), and face greater marital discord (Berger, 1980)
than parents without a history of maltreatment. Lynch (1976) has also
suggested that the children of abusing parents are more aggressive and
hyperactive than normal children, which might add to parental stress
level. These studies have been marred by the fact that adequate controls
for socioeconomic status have not been employed. It has also been
pointed out that stress is not found in all abusing situations (Spinetta &
Rigler, 1972). One study has shown that abusing mothers differed from
controls in their perceptions of their own ability to cope with stress
(Gaines, Sandgrund, Green & Power, 1978). More recently, Plotkin and
Twentyman (1983) found that abusing mothers perceived a standardized series of parent-child problem situations as being more aversive
than did control mothers. These findings suggest that a lower tolerance
for stressful situations may be present in abusive parents than in
matched controls. Bauer and Twentyman (1985) have also found that
abusive but not neglectful mothers were more annoyed than comparison mothers by both child-related and non-child-related aversive stim-
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Sandra T. Azar and Craig T. Twentyman
uli. Again, this suggests that abusive parents may be hyperresponsive to
stimuli and perceive the same stimuli as more aversive than matched
comparison parents. More evidence is needed, however, to substantiate
this view of the etiology of abusive incidents.
2. Social Competency
It has also been suggested that abusing parents have deficits in general
social competency and, in particular, parenting skills. Marital relationships of abusing parents have been shown to involve considerable discord (Ebbin, Gollub, Stein, & Wilson, 1969; Elmer, 1977; Gil, 1970; Smith,
Hanson, & Nobel, 1974; Blumberg, 1974; Flynn 1970; Galdston, 1965;
Gelles, 1973; Green, Gaines, & Sandgrund, 1974; Johnson & Morse, 1968;
Smith, 1975). However, none of the studies cited employed a formal
assessment procedure.
Some of the same data used to support the view that abusive parents
have a deficit in their ability to cope with stress can also be used to
support a conceptualization of abuse based on social skills deficits (e.g.,
higher percentages of abusers are unemployed). Somewhat stronger
evidence for deficits in social skills, however, comes from research
documenting the social isolation of parents who maltreat their children
(Young, 1964; Bakan, 1971; Bennie & Sclar, 1969; Giovanni & Billingsley,
1970; Kempe, 1973; Light, 1973; Polansky, Chalmers, Buttenweiser, &
Williams, 1979; Zalba, 1966). Obviously, lack of a support system can
have far-reaching impact on an individual's stable functioning.
Caplan (1976) described some functions that a support system plays in
preventing dysfunction: (1) collecting and disseminating information
about the world; (2) providing feedback and guidance about behavior
and affect; (3) providing a source of ideology; (4) aiding in problem
solving; (5) providing concrete aid and service; (6) establishing a haven
for rest and recuperation; (7) establishing a reference group; (8) contributing as a source of validation of identity; and (9) enhancing emotional
mastery. Having such a support group acts as a source of psychological
strength and has been posited as a buffer against stress (Caplan, 1976).
Deficits in the ability to acquire such a group, plus higher levels of stress,
may increase the risk of abuse. For example, Garbarino (1976) found
that stress without adequate support systems accounted for 3 6 % of the
variance in rates of child abuse/maltreatment across his sample of
counties in New York state. Moreover, data on personality traits in
abusers implicate broad forms of behavioral deviancy which might interfere with adequate functioning in social relationships. While Gelles
(1973) has noted a striking lack of agreement on the traits found, nevertheless, they may suggest target areas where specific behavioral deficits
might be found. The most frequently cited ones are narcissism, imma-
Assessment and Treatment of Child Abuse
243
turity, rigidity, compulsivity, anxiety, and lack of empathy, all of which
would be detrimental to the formation of adequate support systems.
3. Parenting Skills
Being an effective parent involves acquiring a number of specific
parenting skills and obtaining specific information, such as knowledge
of child developmental stages. Child abusers have been found to have
been younger than control mothers at the time of birth of their first child
(Holmes, 1978), suggesting less maturity which clearly would be detrimental to optimal parenting behavior. Further, they have been hypothesized to have had aggressive role models in their own parents, although
the literature on the multigenerational model has been called into question (Potts, Herzberger, & Holland, 1979). To these parents, aggressive
behavior may, therefore, be a "natural" part of parenting.
A number of behavioral observation studies have clearly delineated
parenting behaviors which differentiate maltreating parents. Behavioral observations of abusing mothers with their infants have shown
them to be less stimulating auditorily and tactilely (Dietrich, Starr, &
Kaplan, 1980) than control mothers. Another observational study found
such mothers to be less sensitive to child cues, less responsive to distress
cues, and lower in socioemotional growth-fostering behavior (Bee, Disbrow, Johnson-Crowley, & Barnard, 1981).
Burgess and Conger (1978) found abusing parents to interact less with
their children than controls and to be more negative in the little interacting they do. Reid and Taplin (1976) also found high levels of aggression in these parents. In a study in our laboratory (Plotkin &
Twentyman, 1984), 36 mothers and their children were observed in
their homes for 4.5 hours over the course of 3 days. Three groups of
mothers participated in this study: those with a known history of child
abuse, those with a known history of serious neglect, and those without
any known history of child maltreatment. Results indicated that the
abusing mothers had very high rates of physical aggression relative to
the other groups and that the neglecting mothers showed the lowest
rates of social interaction. Both the abused and neglected children had
high rates of physical aggression and the abused children also demonstrated more noncompliance than the other children. Thus, evidence
exists suggesting that abusive parents lack effective parenting skills and
that it is in these situations that child maltreatment has been reported
frequently to occur (Dubanoski, Evans & Itiguci, 1978; Gil, 1970). It has
also been suggested that abusing parents have inadequate disciplining
repertories (Reid & Taplin, 1976), are inconsistent in their disciplining
(Reid & Taplin, 1976; Smith & Hanson, 1975; Young, 1964), and have
difficulty setting and maintaining behavioral limits with their children
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Sandra T. Azar and Craig T. Twentyman
(Friedman & Morse, 1974). Finally, the parents also report little discussion occurring between them and their partners regarding discipline
(Young, 1964).
4. Cognitive Distortions
Several studies have also shown lack of developmental knowledge in
abusing parents (Elmer, 1977; Blumberg, 1974; Galdston, 1965; Steele &
Pollock, 1968; Young, 1964). Such lack of knowledge can lead to unrealistic expectations about children's behavioral capabilities and even
misattributions about actions.
For example, Larrance and Twentyman (1983) found that abusive
mothers in particular held negative expectations for their children.
Moreover, the abusing mothers made more internal and stable attributions about their child when their own child was described as misbehaving while comparison mothers showed a somewhat opposite result.
Neglectful mothers did not respond differentially to their own or another child on the attributional measures.
Plotkin and Twentyman (1983) also found that both abusing and neglectful mothers made more negative attributions to their child than did
comparison mothers. In addition, the maltreating mothers responded with harsher punishment to experimental vignettes and punishment was systematically related to parental perceptions of the child's
intentionality. Bauer and Twentyman (1985) found that abusive
mothers reported their child as acting to annoy them more than either
neglectful or comparison mothers across a number of laboratory situations.
There is also suggestive evidence from other laboratories that abusing
parents may have cognitive misperceptions. Frodi and Lamb (1978a)
found that abusers responded to videotapes of both crying and smiling
infants as aversive both on physiological measures and on a mood
checklist. Gregg and Elmer (1969) found that maltreating mothers saw
their babies as very difficult to care for, while technicians on the project
thought in many cases the babies were less difficult than the average.
The widely held psychodynamic theory of role reversal (Morris &
Gould, 1963) can also be conceptualized as a process in which faulty
cognitions (for example, "My child should meet my needs for love and
attention") occur (Twentyman, Rohrbeck, & Amish, 1984) and lead to
abusive behavior. Such faulty cognitions might remain unchallenged
since social isolation is common among abusers. Also, in many cases, the
spouse may not correct the cognitive distortions for fear of reprisal or for
other reasons (Steele & Pollock, 1968).
Assessment and Treatment of Child Abuse
245
In addition to distorted cognitions about the child, the abusing parent
may have distorted cognitions which are more generalized. Melnick
and Hurley (1969), for example, found that their sample of abusing
mothers had a lower sense of personal worth as measured by the California Personality Inventory (CPI). Shorkey (1980), attempting to replicate
this finding, found that the abusing mother felt a strong sense of self-esteem, but had a poorer sense of self-worth when asked about others'
perceptions of her. This suggests what might be a pervasive cognitive set
of feeling unjustly evaluated by others.
Conger, Lahey, and Smith (1981) found in a small sample of mothers
that abusing mothers had Beck Depression Inventory scores more than
double those of controls. This gives further credence to the idea of a
negative cognitive schema in abusing parents. The presence of such
distracting cognitions has been shown to decrease the positive and increase the negative interactions of parents with their children (Zussman, 1980).
5. Impulsive Control
A final cognitive-behavioral deficit in child-abusing parents is their
inability to control angry impulses. Often the main evidence for claiming lack of impulse control is the occurrence of the abusive incident,
which, as Parke and Collmer (1975) have pointed out, is tantamount to a
tautological argument. Disbrow, Doerr, and Caulfield (1977), however,
have found generalized heightened arousal patterns in their abuse sample and Frodi and Lamb (1978a) found similar arousal patterns to both
child crying and smiling. This suggests that these parents might be more
likely to respond in a violent manner than other parents.
Assuming that a higher level of stress exists for the abuser and that a
higher probability of having had an aggressive parental role model
exists, frustration level would be high and physical violence would be a
dominant response in these parents' repertoire. It has also been suggested that conflict that began between spouses may also result in violence toward the child (Steinmetz, 1977).
Impulsivity within abusing families has been studied directly using a
multimodal approach. Rohrbeck and Twentyman (1986) examined impulsiveness in abusing, neglectful, and matched comparison mothers
and their preschool children. These authors employed a multimodal
assessment procedure including behavioral, cognitive, and rating scale
data. The results indicate that on several measures abusing mothers
were more impulsive than the matched comparison mothers. Results
from the children's data, however, did not reveal strong differences.
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Sandra T. Azar and Craig T. Twentyman
Β. The Child
Spinetta and Rigler (1972) noted that most of the research in the child
abuse area does not focus on the child. This statement remains true
today. Furthermore, even when data are collected, they tend to be
demographic and archival rather than observational (Barahal et αϊ.,
1981). This situation is unfortunate given that the child's behavior has
been posited as a causal factor in the abuse (Millow & Lowrie, 1964) or as
maintaining maltreatment (Parke & Collmer, 1975).
For both preventive purposes and for intervention with the child once
abuse has occurred, an understanding of the relationship between the
abused child's behavior and the abusive incident is crucial. From a
behavioral standpoint, the same dysfunctional patterns of behavior
found in the abusing parent are likely to be found in the children. That
is, if the postulates of social learning theory hold true, deficits in the
child should closely parallel those found in the parent. Through modeling and selective reinforcement the child is likely to develop poor social
skills, perhaps exhibit social isolation, be more prone to aggressive behavior, have difficulty with stressful situations, and show various cognitive problems. In addition, from a strict behavioral perspective, these
children should show deficits resulting from a lack of stimulation and
the effects of excessive use of punishment given the low p a r e n t - c h i l d
interaction level and high level of negative affect expression by the
parents, as noted earlier.
While there are currently limited research data available, there is
some evidence that the above predictions do have some validity. However, the relationship between parent behavior and child behavior is
not unidirectional (i.e., the parent does not exclusively affect the child's
behavior, the child's can also affect the parent). We could easily have
placed the section on deficits in the child first and then predicted deficits found in the parent. Only long-term longitudinal prospective studies will be able to provide an understanding of the relationship between
parental and child interactions.
Since a substantial amount of abuse occurs during the child's first 2
years of life it is important to understand the behavioral difficulties that
may occur early in such children's lives. Birth complications, prematurity, and low birth weight are found in greater proportions in abused
populations than in nonabused children or among nonabused siblings
(Fontana, 1964; Green et αϊ., 1974; Klein & Stern, 1971; Lynch, 1976).
However, some studies have failed to replicate these results (Baldwin &
Oliver, 1975; Berger, 1980; Starr & Dietrich, 1981). Prematurity has been
associated with more aversive and difficult behavior, which might
heighten parental frustration. Frodi and Lamb (1978b), for example,
Assessment and Treatment of Child Abuse
247
found premature infants' cries produced higher arousal and elicited
higher ratings of aversiveness than did full-term infants' cries.
Certainly an infant who is sick is also a greater source of worry to the
parents and presents more difficulty in caretaking. One study by Harrington (1972) noted that abused infants have sleep and eating disturbances, cry excessively, and respond poorly to caretakers' attempts to
comfort them when upset. This condition certainly produces stress.
Another study, however, failed to show differences in maternal reports
of temperament between abused infants and nonabused but physically
ill infants (Starr & Dietrich, 1981).
Cognitive deficits have been noted among abused children. For example, Elmer and Gregg (1967) found 5 0 % of their sample to be mentally
retarded. Birrell and Birrell (1968) considered two-thirds of their sample
to be retarded, a figure also found by Martin (1972). Smith (1975) reported that his sample of abused children scored significantly lower
than a control group on measures of cognitive ability. Hoffman-Plotkin
and Twentyman (1984) found that both abused and neglected preschoolers scored lower on a number of cognitive tests (e.g., the Peabody
Picture Vocabulary Test and the Stanford Binet) than did matched comparison children. Dietrich et αϊ. (1980) point out, however, that the
effects of abuse can interact with other factors, namely physical neglect.
In studies which broke the samples down into abused and abused plus
physical neglect, the latter group showed greater developmental delays
(Elmer & Gregg, 1967; Martin, Beezley, Conway, & Kempe, 1974; and
Smith, 1975). Many children who have been physically abused are also
reported to be undernourished and this may also affect their responses
to cognitive tests (Elmer & Gregg, 1967; Heifer & Pollock, 1968; Koel,
1969; Martin et αϊ., 1974; Smith, 1975).
Cognitive deficits may also result from a lack of maternal responsiveness, which has been found to exist in maltreating families (Bee et αϊ.,
1981). Since an extensive literature exists relating maternal stimulation
and cognitive growth (Spitz, 1945; Dennis & Najarian, 1957; White &
Castle, 1964; Lewis & Goldberg, 1969), these factors should be considered before attributing causality between abusive incidents and cognitive deficits. Children who are deprived of normal caretaking stimulation are described as being unresponsive. This may perpetuate parental
unresponsiveness, further producing unresponsiveness in the child.
Maltreated children also exhibit specific developmental delays in
speech and language (Martin, 1972; Smith & Hanson, 1975; Elmer et αϊ.,
1975; Blager & Martin, 1976). Elmer et al.'s (1975) 8-year follow-up study
of abused children, while showing that many differences disappear over
time, found that delays in speech and language did not disappear. Blager
and Martin (1976) showed that the younger abused child exhibits more
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Sandra T. Azar and Craig T. Twentyman
striking delays and deficits. These authors noted that spoken language is
learned through practice with an interested adult correcting and expanding upon it, and that such attention may not be present in an
abusing home where it may even be dangerous to speak.
Martin (1976) also reports deficits in gross motor development in
abused children. Relich, Giblin, Starr, and Agronow (1980) further qualified this finding. When they compared abused and nonabused children, no differences in mother behavior were noted. Yet when they
broke down their sample on the basis of quality of home environment as
defined by mothers' "avoidance of restriction and punishment," the less
favored abused group (e.g., the one high on mother's avoidance of
restriction and punishment) was found to exhibit more self-manipulation of objects than the favored abused children.
Dysfunctional social behavior has also been found in maltreated children. Galdston (1965), in his observations of abused boys, found a high
incidence of unpredictable, purposeless, violent behavior. Girls, however, were more likely to show clinging or isolated behavior. In another
study, Baldwin and Oliver (1975) report high frequencies of fear of
adults, withdrawal, listlessness, hyperactivity, and irritability in an
abused sample of children.
Aggressive and destructive behavior as well as poor frustration tolerance have often been noted in abused children (Green, 1978; Kent,
1976). Martin and Beezley (1976) looked at a sample of 50 abused children and found the following characteristics: (1) impaired capacity to
enjoy life, (2) symptoms (enuresis, tantrums, hyperactivity, bizzare behavior), (3) low self-esteem, (4) learning problems in school, (5) withdrawal and oppositional behavior, (6) hypervigilance, (7) compulsivity,
and (8) pseudomature behavior.
In a behavioral observation study in a day care setting, George and
Main (1980) found extreme differences in the social behavior of abused
toddlers ( 1 - 3 years old) and matched controls. The abused infants were
much less likely than controls to approach their caregivers in response
to friendly overtures. When they did approach, they did so in an unusual manner (i.e., to the side, to the rear, or by turning about and
backstepping). These infants also were more likely to avoid the friendly
approaches of peers and caregivers. Their approach behavior was more
ambivalent (i.e., a mixture of approach and avoidance).
A lack of responsiveness and avoidance on the part of abused children
was observed by Bee et αϊ. (1981) in a mother-child interaction study. In
this study, lack of responsiveness included lower levels of looking at the
parents face or eyes when they attempted to make eye contact, responding unusually to maternal physical and verbal behavior, and lower
attentiveness to the task. Hay and Hall (1981) also found that abused
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children exhibited less than half the number of positive physical contacts as controls in a m o t h e r - c h i l d interaction session. Children also
exhibited shorter vocalizations, longer silences, and less total vocalizing
than matched controls. Gaensbauer and Sands (1979) in observing
abused and neglected infants in a structured laboratory setting found
them to have a variety of distorted affective communications. These
authors suggest that this interferes with mutual engagement a n d / o r
elicits negative responses in caretakers. Such behaviors include affective withdrawal, lack of pleasure, inconsistency and unpredictability of
affective communications, "fickleness" in affective behavior [what
Martin (1976) calls "indiscriminant attachment"], ambiguity in affective expression, and higher frequency in the use of negative affective
expression (e.g., distress, anger, and sadness).
Aggressive behavior has also been found to be characteristic of abused
samples. George and Main (1980) found that abused children were more
likely to physically assault their peers and "harass" caregivers verbally
and nonverbally. They also were the only infants in the day care setting
who assaulted or threatened to assault caregivers. Looking at slightly
older children (approximately age 6), Reidy (1977) also found that
abused children exhibited more aggression in a school setting, expressed more aggression in the Thematic Aperception Test responses
than neglected and normal matched controls, and received higher aggression ratings from teachers.
Hoffman-Plotkin and Twentyman (1984) observed abused and neglected preschool children and found that the abused children were
more aggressive than the comparison children and the neglected children showed the least amount of social interaction with other children.
Bousha and Twentyman (1984) also found abused children to be more
aggressive in a home observation study, but in this study the neglected
children were also more aggressive than the matched comparison children. These authors also found that the abused children were more
noncompliant and that both groups of maltreated children had fewer
social interactions than the comparison children. Overall then, it appears that aggressive behavior is a significant problem for maltreated
children.
Barahal et αϊ. (1981) explored the social cognitions of abused 6- to
8-year-old children. They found that abused children were more likely
to feel that outcomes were determined primarily by external factors.
These children also showed a tendency to be poorer at being able to
identify feelings and notice affective changes in context. Abused children also were more deficient in perspective taking skills when compared to controls. Such results are suggestive of more subtle cognitive
deficits than have been explored to date. Moreover, Smetana, Kelly, and
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Twentyman (1984) also found differences between neglected and comparison children on measures of their concepts of social justice.
Sroufe and Egeland (1981) found evidence of poor problem-solving
skills in abused infants using a tool-using problem. This study is interesting in that it was a prospective study which compared abusing, neglecting, "emotionally unavailable," and matched comparison mothers.
Results indicated that the worst outcome was in the emotionally unavailable group. This finding combined with Relich et al.'s (1980) results
indicates that specific qualities in parenting determine deficits found in
the child and it is not simply a matter of the occurrence of an abusive
incident.
Considering the deficits and cognitive problems that have been noted
in both the parent and the child, it would be useful to outline a
cognitive-behavioral approach that might be employed in assessing
and treating abusing parents and abused children.
III. COGNITIVE-BEHAVIORAL ASSESSMENT IN CHILD ABUSE
Comprehensive assessment typically occurs in three response modes
(i.e., physiological, overt behavior, and cognitive responses). A number
of assessment approaches are already established in the literature and
can easily provide a framework for developing a standardized evaluation procedure in child abuse.
One such assessment format is the seven-part analysis suggested by
Kanfer and Saslow (1969): (1) initial evaluation, (2) clarification of problem situations, (3) motivational analysis, (4) developmental analysis of
the individual, (5) analysis of self-control, (6) analysis of pertinent social
relationships, and (7) assessment of the individual's social, cultural, and
physical environment. In describing the more specialized cognitivebehavioral assessment, Meichenbaum (1976) notes that two important
areas must be assessed: (1) What is the content of the client's cognitions
that interfere with adaptive behavior? (2) What is the client failing to say
to himself which, if present, would lead to adequate performance and
adaptive behavior?
Behavioral assessment, if it adequately obtains information on the
various response modes, uses a variety of data collection methods. Interview procedures are employed to help delineate problem situations.
Imagery, role playing, and self-monitoring are employed to establish
baseline frequencies of problem behaviors and the relevant cognitions
associated with such behaviors. Standardized inventories are also used.
Some examples are the Beck Depression Inventory, problem-solving
questionnaires, and means-ends thinking (Beck, 1976; D'Zurilla &
Goldfried, 1971; Spivack & Shure, 1974).
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Although the above techniques were not specifically designed for
child abuse populations, they could easily be modified and applied to
abusing families. The techniques seem especially attractive for use with
abusing populations as a large majority of those coming for treatment
are from low socioeconomic backgrounds and action-oriented methods
would be much more appealing to such clients (Lorion, 1978). Moreover,
the attributional measures used in several of our studies could also be
employed with maltreating populations (Bauer & Twentyman, 1985;
Larrance & Twentyman, 1983). Cognitive-behavioral measures also
may be less open to social desirability biasing, which would be particularly important since most abusers are involuntary clients. Thus, they
might also have more face validity than would traditional techniques.
How then might a behavioral assessment be conducted with the abusing
parent in the home environment (i.e., family interaction patterns) and
with the child?
A. Assessment of the Parent and Family Interaction
Based on the deficits outlined earlier, an assessment program might
be constructed along a number of different dimensions. First, a thorough
history of parents' own child-rearing history needs to be collected covering frequency and severity of the use of physical punishment and use
of alternative methods of discipline. In light of the documented unreliability between actual observations of maternal behavior and maternal
reports of their own parenting (Yarrow, Campbell, & Burton, 1968), the
accuracy of self-reports in this group can be questioned. This is especially the case given that motivational factors (e.g., selective forgetting
or exaggeration) are particularly likely to influence reports of family
violence. If possible, a number of respondents including the parents'
parents should also be interviewed. Even with this data, however, there
are problems because of the retrospective nature of the data and the
possibility that social desirability factors may influence responding. The
individual's experience with parenting behaviors (i.e., with siblings or
babysitting) prior to the birth of their children should also be collected
as it may provide information about prior social skills and learning
histories. The parents' rememberances surrounding pregnancies and
evaluation of hospital birth records provide valuable insight into how
the parents approached parenthood and any significant factors which
may have influenced the early m o t h e r - c h i l d relationship (e.g., birth
complications, difficult baby).
A second aspect of assessment should focus on the parents' current
marital relationship and other interpersonal resources. Data on number
of friends and frequency of social contacts with friends and family
should be elicited. Factors inhibiting social contact should be noted
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(e.g., lack of phone, no transportation, location of home, work schedule,
social skills deficits observed during interview contacts). An excellent
example of a factor inhibiting social relations occurred in interviews
with one of the authors' clients. During interviews she talked with her
hand over her mouth which interfered with understanding her vocalizations and set up social distance. It later became apparent that her
reason for doing this was the presence of extremely unsightly teeth. A
simple dental intervention resulted in a change in her behavior (i.e., she
no longer placed her hand in front of her mouth), which greatly increased her social interactions.
Assessment specifically geared to parenting should include an evaluation of the parents' knowledge of child development, attitudes toward
child rearing (endorsement of and feelings about use of various child
management techniques), and behavioral measures of present level of
child management skill and family interaction. Data on the parents'
view of child problem behaviors, as well as an independent evaluation,
should also be collected. The current level of stress and capabilities for
coping and anger control should also be tapped. In addition, to rule out
gross pathology, some assessment should be made of personality functioning.
A final area that should be assessed prior to therapy is the client's
motivation for treatment. Particular resistances to the therapeutic process should be discussed with the client as a way of increasing compliance and efficacy. Whenever possible, assessment procedures should
include multiple data sources (e.g., parent, spouse, friends, family, and
case workers).
At this point a concrete example of an assessment battery from our
own work might be helpful. At Mount Hope Family Center, a treatment
center for child abuse and neglect (Twentyman, Azar, Bousha, & Rohrbeck, 1980), a number of assessment procedures have been used, and
these represent an example of how a cognitive-behavioral approach
might be conducted. Assessment at the Center begins with an informal
intake interview, which taps parental history and motivation for treatment. Then a number of inventories are completed, and data on social
relationships are collected. These include (1) the MMPI; (2) the
Holmes-Rahe Scale, tapping level of stress; (3) social contacts questionnaire; (4) Busse Durke Anger Inventory; (5) the Locke Wallace Test; (6)
the m e a n s - e n d problem-solving test; and (7) reports from the family's
caseworker. To assess their responsiveness to stress one might give them
a set of child-rearing situations with different levels of aversiveness and
ask them to note the aversiveness. This has been shown to differentiate
maltreating parents from nonmaltreating ones (Plotkin & Twentyman,
1983).
Assessment and Treatment of Child Abuse
253
To complete the evaluation the families also participate in a number
of situations which are coded using a behavioral observation system. To
ensure that an adequate sample of situations is assessed, observations
are typically conducted in the home (in which detailed behavioral observations of social interaction and negative and positive affect expression are collected) and in other settings. Even short observations have
been shown to differentiate maltreating parents from comparison
groups (Bousha & Twentyman, 1984). Another observation takes place
in a laboratory setting and has two components: parent-child teaching
interaction and an assessment of child management skills.
B. Assessment of the Child
Since the child is typically the focus of the initial investigation into
whether abuse has occurred, a discussion of assessment difficulties is
warranted. For example, both the reliability and validity of the young
child's reports of abuse can be questioned as he or she may not have the
ability to fully articulate his concerns or adequately represent him- or
herself. Identification usually rests upon the judgment of a third party.
Fraser and Martin (1976) note that identification of abuse relies on two
basic assumptions: (1) that this third party is capable of identifying signs
of abuse, and (2) that he or she is willing to report the abuse. In an effort
to compensate for past failure to identify abusive cases to authorities,
states have passed mandatory reporting laws. Despite this, a number of
factors still inhibit the identification of abuse. Moreover, potential
biases have been found to enter into judgments of whether abuse has
occurred. Thus, Turbett and O'Toole (1980) found that physicians were
more likely to label minority or lower socioeconomic class children as
abused, leaving one to wonder whether mislabeling occurred or
whether labeling followed real differences in base rates among the different socioeconomic and racial groups. Moreover, Giovannoni and Becerra (1979) found that identification of abuse varied across professional
groups, as well as across different ethnic groups.
In addition to social biases, making the determination of abuse based
solely on physical signs is difficult. Schmitt (1980) offers behavioral
criteria for identifying child abuse. These criteria include the failure to
provide a creditable history for injuries, typical sites for bruises, the
presence of handmarks, and a list of inflicted abdominal injuries. For
example, in the history provided by the parent, a number of factors
should be considered. These include (1) eye witness reports, (2) unexplained injury, (3) implausible history, (4) alleged self-inflicted injury,
and (6) delay in seeking medical care. While the delineation of behav-
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ioral criteria are helpful, their reliability and validity need to be documented to ensure their accuracy and utility for general use.
Once identified, the emphasis in the past has been on the evaluation
of the child's physical state (Martin, 1976). This continues to be the
major focus of assessment. The professionals who become involved at
this point are usually medical, legal, and social service agency personnel, none of whom is trained or expert in normal development or in the
identification of psychological problems or developmental disabilities.
As noted earlier, while gross developmental delays or psychological
disturbances may be obvious even to the untrained eye, more subtle
deficits may not be apparent or may manifest themselves only over time.
Social workers, psychologists, and pediatricians need simple operationally defined screening devices which can help them refer the child for
needed services. Rodelheffer and Martin (1976) strongly recommend
that developmental assessments be done on each abused child. Also, it
might be added that since abuse may be only one of several factors
having a negative impact on the child, all the children in the family
should be assessed as well.
Based on the deficits discussed earlier, any assessment of an abused
child should include the following components: (1) a detailed developmental history, (2) a physical examination of the child (especially of the
neurological system), (3) a formal developmental test (including intellectual, perceptual motor ability, and speech and language evaluations),
and (4) a behavioral observation of the child interacting with parents,
other adult caretakers, and peers.
Rodelheffer and Martin (1976) note a number of problems that arise in
this assessment process. If abusing parents have distorted views of their
children, an accurate developmental history may not be possible to
obtain. Social desirability also becomes a factor in their responding,
especially considering their legal jeopardy with having physically injured their child. Developmental data can also be obtained from newborn nursery records and other medical reports, preschool or day care
records, and the informal observations of caseworkers, foster families,
friends, and neighbors of the child.
Psychological testing and cognitive testing in particular may provide
the most data about the current deficits in the child, but Rodelheffer and
Martin (1976) point out that the testing situation may present particular
difficulties to an abused child which interfere with obtaining accurate
results. Having had a past history with a punitive adult, the abused child
may approach the situation with anxiety and fear. Abused children
have been observed to be hypervigilant and as seeking approval from
adults, which may distract them from the task at hand. Other behaviors
noted which may interfere with an accurate assessment include diffi-
Assessment and Treatment of Child Abuse
255
culty in attending to instructions, verbal inhibition, failure to scan, and
passive-aggressive and resistant behavior. Modification of standard
procedures may be necessary. All these factors make behavioral observation in naturalistic settings a less contaminated data source. Some
studies (e.g., Hoffman-Plotkin & Twentyman, 1984) have shown that
such observational data can differentiate abused children from
matched comparison children on measures of aggression and social
interaction in a preschool setting.
IV. INTERVENTION
Abusing families present the cognitive-behavioral therapist with a
number of immediate problems. First, there are reactions to the serious
injury or neglect of a child that may interfere with effectively working
with the perpetrator of the injury or neglect. Steele (1975) noted the two
reactions most therapists have: (1) denial and (2) a surge of anger and an
urge to scold parents. Both reactions are destructive to establishing a
therapeutic relationship. A behavioral approach may prove useful to
inhibit these reactions in that it assumes the problem is a learned one,
not something intrinsically "bad" about the parent. It also is a direct
approach which provides a clear delineation of the areas needing
change.
Because the treatment is frequently involuntary, some degree of noncompliance with treatment is inevitable. This situation can be particularly difficult for the therapist in that many behavioral programs involve tasks to be completed by clients (e.g., homework, data collection).
Motivation is a problem that must be tackled from the very outset of
treatment. Some programs have successfully used incentives (e.g.,
money, movie tickets) to aid in compliance (Ambrose, Hazzard, & Haworth, 1980). Whether such incentives produce long-term effects has
not yet been determined.
Demographic data would indicate that many abusive parents are less
well educated and of lower socioeconomic class. Both of these characteristics are associated with poor attendance rates in therapy (Lorion,
1978). Techniques typically used with middle-class clients may be less
effective (e.g., training in child management skills; Graziano, 1977) with
abusing populations. They must be simplified in order to be employed
effectively with such clients. Other pragmatic problems exist. For example, these clients are less likely to have phones and transportation
and this can inhibit regular contact. As a solution to this problem, we
have provided families with transportation. Frequently, sessions are
also held in the home.
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Treatment of abusing families requires more outreach than is normally the case in traditional therapy with middle-class clients. Martin
and Beezley (1976) suggest the use of a lay therapist in addition to formal
therapy to provide the parent with a "reparenting experience." Behaviorally this would translate into a new role model for parenting and
friendship behavior (e.g., "a transfusion of mothering"; Court & Kerr,
1971) and a source of information for parenting and problems. Also,
because of the extent of the skills deficits found, it is possible that
long-term treatment may be required.
Finally, mandatory reporting of suspected abuse may also interfere
with the therapeutic relationship. In order to minimize the effects of
this, the possibility that this may occur needs to be firmly and openly
acknowledged from the outset of treatment.
A. Intervention with the Parent
Many authors have suggested that the use of behavioral techniques
with abusers might be fruitful (Ambrose et αϊ., 1980; Burgess, 1978;
Conger, 1980; Christopherson, Kuehn, Grinstead, Barnard, Rainey, &
Kuehn, 1976; Tracy & Clark, 1974). Heifer (1980), for example, suggests a
"skill relearning" program for adults who had poor parenting histories.
The program is essentially a systematic desensitization program to relearn behaviors which have been associated with negative affective
experiences (e.g., touching, feeling expression). Some exciting preliminary individual and group behavioral work has already taken place
with abusers. Unfortunately, much of this work has been descriptive
a n d / o r poorly controlled. Treatment techniques and outcome measures have also not been well documented (Isaacs, 1982).
Carter, Reed, and Reh (1975) described a nursing-led team intervention effort aimed at increasing home management, child care, and
m o t h e r - c h i l d interactional skills. The team consisted of a nurse, a paraprofessional home health aide, a nutritionist, and, on a limited number
of cases, a psychiatric social worker. Their approach is described as
emphasizing positive social reinforcement of appropriate behaviors and
role modeling. They compared the effects of long-term intervention (6
months) versus short-term interventions (2 months) with abusing and
neglecting mothers and compared home management, clothing care,
safety practices, communication skills, and nutritional practices. The
long-term group improved significantly on all of the variables studied
except safety practices. The short-term group showed improvement in
crucial mother-child interactional skills. When rehospitalization in
the two treatment groups was compared with a matched no treatment
group, it was found that 9 0 % of the control children were rehospitalized
Assessment and Treatment of Child Abuse
257
over the 6-month period, whereas none of the children in the treated
group was. The results of this study are open to question, however, since
intervention was not well defined and improvement appeared to be
rated by the same individuals providing treatment. This study is important in that it suggests that length of treatment may be a critical variable
in producing effects.
Gilbert (1970) employed behavior modification techniques in the case
of an abusing mother. Target behaviors were developed with the mother
and modeled by the therapist. These behaviors included (1) reading to
her child, (2) playing indoor games, (3) sitting next to her child, (4)
conversing with her child, (5) sitting down with the child on her knee,
(6) taking the child out for a walk, (7) putting her arm around the child,
(8) hugging her child, and (9) cuddling her child. All target behavior
were at almost zero frequency at baseline. All behaviors increased over
the 10-week treatment period and all increased or maintained their
frequency at 2-month follow-up. The outcome was, however, measured
by self-monitoring done by the mother, thus raising questions about the
results.
Sandler, VanDecar, and Milhoan (1978) described a behavioral training procedure in the use of positive reinforcement that they employed
with two abusing families. They trained the parents for nine sessions to
increase the rate of behaviors labeled approval and physical
positive.
The parents, both single parents and mothers, completed assigned readings and the respective review tests in Becker's (1971) Parents are
Teachers. Also included in training were weekly handouts focusing on
specific child management behaviors (Tarns & Eyberg, 1976). Role playing was employed in the training and tangible reinforcers were given for
completion of homework assignments (e.g., free restaurant meals and
movie passes). Home observations using the Patterson Coding System
(Patterson, Ray, Shaw, & Cobb, 1969) were done for seven baseline
sessions, throughout treatment, and for two follow-up sessions at 1 and 4
months posttraining. Baseline observations revealed either low levels or
the absence of social reinforcement. The results of training showed
increases in all trained behaviors, some generalization to other prosocial
behavior, and in some cases maintenance of the behavior change at
follow-up.
Conger et al. (1981) detailed an intervention program designed to
modify maternal depression and behavior in five abusing mothers. Results of intervention were compared with data on five matched no treatment controls. Treated mothers were seen individually in their homes
one or two times a week for approximately 1 hour. The average length of
treatment was 3 months. Outcome measures included a symptom
checklist, the Beck Depression Inventory (Beck, 1976), and behavioral
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Sandra T. Azar and Craig T. Twentyman
observation (Burgess & Conger, 1978). Treatment included training in
behavioral child management skills and child development, training in
stress management techniques, relaxation training, and behavioral couples therapy. The treatment package was modified to meet individual
needs of clients. It was found that this behavior-oriented treatment
package significantly decreased abusing mothers use of aversive physical behaviors, increased their use of affectionate physical responses,
improved their child management skills in four out of five cases, and
reduced their degree of depression.
While one must be cautious about generalizing from such small sample sizes, it appears that parent training of behavioral techniques may
have a successful impact on the parenting behavior of child abusers.
Further exploration is clearly warranted. The use of group training with
abusers may also be useful. Groups in themselves can provide an area
for developing social skills and help to break the social isolation of
parents. Parent groups also help parents see they are not alone in their
problems and involuntary clients may be more accepting of advice from
other parents than from professionals. Many group programs employing
behavioral and educational components have been described in the
literature (Ambrose et αϊ., 1980; Thistleton, 1977; Wolfe, Sandler, &
Kaufman, (1980), but only one has been systematically evaluated (i.e.,
used behavioral observations, as well as therapist's report, and used a
control group) and only one has compared behaviorally oriented treatment to another type of treatment.
Wolfe et αϊ. (1980) did group training of eight abusing involuntary
parents in the clinic with competency based training and rehearsal in
the home. A matched control group was employed in the design. They
found that training abusive parents in child management skills and
self-control techniques resulted in improved parenting skills as measured by home observations, parental report of child behavior problems,
and caseworker report of family problems. At 10 week follow-up the
treated group maintained treatment effects. At 1 year follow-up none of
the treated families had been reported or suspected of child abuse.
Twentyman et αϊ. (1984) have formulated a four-stage model of child
abuse. In the first stage, the parent holds unrealistic expectations for the
child, which the child disconfirms (Stage 2). The parent then makes a
misattribution about the child (Stage 3), and finally overreacts, frequently in an impulsive, aggressive manner (Stage 4).
This model has a number of implications for cognitive-behavioral
treatment programs for maltreating parents. First, in addition to training
in effective behavioral management procedures, the therapist would
examine the extent that cognitive dysfunction is related to abusive or
neglectful acts. Second, information directed at improving the parents'
knowledge of their child's developmental sequences would be provided
Assessment and Treatment of Child Abuse
259
to alter unrealistic expectations. Third, modification of a negative attributional style would be encouraged.
Azar and Twentyman (1984) assessed the efficacy of a cognitive behavioral approach with maltreating parents. A sample of 54 parents
was assigned to one of four groups. Each group received either (1) 10
group sessions of cognitive-behavioral training, (2) 10 group sessions of
cognitive-behavioral training plus home visitors to increase the generalization effects, (3) 10 group sessions of insight-oriented psychotherapy, or (4) only the standard Department of Social Services programs and
no additional group therapy sessions. Although treatment results were
modest, some differences among the groups did occur. For example, the
group receiving generalization training showed significantly greater
gains on a measure of unrealistic expectations than the group which
received no generalization training. At posttest there was a trend for all
treatment groups to show a greater number of total interactions in the
home setting than the comparison group and this effect was significant
at the follow-up period. Finally, all treatment groups produced greater
changes in ratings from social service workers. Although the results
from the Azar and Twentyman (1984) experiment are modest, they
provide some documentation for the efficacy of cognitive-behavioral
treatment programs. Unfortunately, however, the brevity of treatment
and a number of other factors may have attenuated treatment effects.
B. Intervention with the Child
The treatment of abused children has received even less attention
than that of the parent. In a bibliography on child abuse and neglect, for
example, 44 articles were listed under the heading 'Treatment of Parents" and only 4 under "Treatment of the Child" (Kalisch, 1978). Welldefined, behavioral interventions with the child are absent from the
literature. The treatment techniques mentioned in the literature include foster care, psychotherapy, preschool experience, crisis nurseries,
and residential family therapy (Martin, 1976). No systematic behavioral
evaluation of such treatments has been completed as yet. The majority
of the suggested interventions involve a major change in the child's
environment (e.g., in caregivers, food, living situation, peers, and involvement of parents) either on a long-term or short-term basis. Such a
change in surroundings which were already threatening can be an
added trauma for the child.
To conceptualize treatment in cognitive-behavioral terms, we have
to consider how each of the above treatment methods can alleviate the
deficits found in abused children. Target behaviors would be developmental delays (especially in language and speech), motor delays, lack of
appropriate social understanding, problem-solving deficits, and behav-
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ioral deviations in peer/adult relations including affective withdrawal
and aggression. Behavioral interventions with children have been
shown to have some success in each of these areas (Ross, 1978). Operant
techniques have been used to work with severe speech deficits
(Wheeler & Sulzer, 1970; Rigley & Wolf, 1967; Stevens-Long, Schwarz, &
Bliss, 1976) and presumably would be helpful with the less severe deficits found in abused children. Behavioral methods have been used to
increase the social interaction between severely retarded children
(Whitman, Mercurio, & Caponigri, 1970) and in 4-year-old nursery
school children (Allen, Hart, Buell, Harris, & Wolf, 1964). Spivack and
Shure (1974) have demonstrated the effectiveness of training in problem-solving skills. Impulsive and aggressive behavior and attentional
problems have also been dealt with successfully in children using
cognitive-behavioral and operant approaches (Bornstein & Quevillon,
1976; Kendall & Braswell, 1985; Meichenbaum & Goodman, 1971; Patterson & Reid, 1973).
Some caution must be exercised in the involvement of parents in the
use of behavioral methods with their children. Careful monitoring of
parental involvement in treatment and the use of sources of data independent of them should be employed. Punitive and poorly educated
parents may either misuse or misinterpret the procedures. Also, because of hypothesized cognitive distortion pertaining to the child, their
reports of behavior may be inaccurate. Because the child has undergone
trauma and lived in a chaotic and punitive home environment, certain
common elements of intervention should be employed no matter what
dispositional choice is made. These include developmental stimulation,
opportunities for socializing with peers and positive adult figures, and
safeness (i.e., a warm, nurturing environment, low in punitiveness)
(Martin, 1976). Changing the child without intervening with the family
as a whole may prove not only fruitless, but harmful to the child. Helping the child become more verbal and curious about the world could be
disasterous if the child returns to a home where verbal initiations on
his/her part are punished. Behavioral treatment of the parent can help
foster positive change in the child's behavior (Sandler et αϊ., 1978).
Controlled studies of the effects of treatment and differing dispositions on the child need to be done. Behavioral techniques have demonstrated usefulness in the treatment of deficits posited to occur in abused
children and, therefore, might be applied to this area.
V. SUMMARY
The maltreatment of children has been shown to have behavioral and
cognitive antecedents and sequelae. Approaching the problem from a
behavioral skills deficit and cognitive dysfunction perspective may
Assessment and Treatment of Child Abuse
261
have utility. Behavioral research methods would greatly improve the
scientific rigor of the research being done and have already begun to
improve our understanding. Some evidence already exists supporting
the view that cognitive-behavioral approaches may be successful in
treating abusive and neglectful populations.
REFERENCES
Allen, K. E., Hart, B. M., Buell, J. S., Harris, F. R., & Wolf, M. M. (1964). Effects of social
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Index
A
Absolutistic thinking, depressive beliefs
and, 95
Accident victims, causal attributions and
adjustment, 2 0 0 - 2 0 3 , 206, 207, 210, 221
chance, 217
other-blame, 215, 216
Achievement, causal attributions in
health and illness and, 184, 185
Action, psychotherapy, hot cognition and,
144, 172, 173
cognitive psychology, 146-148
emotion, 161
emotional synthesis, 161
integrative theory, 156
Activating event, emotion and, 145
Addiction, causal attributions, smoking
and, 189, 190
Adjustment
to illness, attributions in, 200
antecedents of, 2 0 0 - 2 0 4
consequences of, 2 0 4 - 2 0 9
control, 2 1 3 - 2 1 5
health interventions, 223
measures of, 221
recovery, 191
self-blame, 2 0 9 - 2 1 3
sociodemographic factors, 203
sophistication, 203, 204
rational-emotive model and, 63, 67, 82
states of mind and, 2
Affordances, psychotherapy and, 158, 159
Age
adjustment to illness and, 203
states of mind and, 50
Aggression
causal attributions in health and illness
and, 182
child abuse and, 246, 248, 249, 255
coping, 241
impulse control, 245
intervention, 258, 260
parenting skills, 243
psychotherapy and, 157
states of mind and, 27
Agoraphobia, states of mind and, 44, 51, 52
Ambivalence, see Internal dialogue of
conflict
American Journal of Psychology, Beck's
cognitive therapy and, 91
Anger
causal attributions in health and illness
and
adjustment, 2 0 5 - 2 0 7
other-blame, 215 217
child abuse and, 249
family interactions, 252, 253
impulse control, 245
depressive beliefs and, 91
psychotherapy and
adaptive role of, 157
emotion, 163, 164
maladaptive cognitions, 167, 168
motivation, 166
rational-emotive model and
discriminant validity, 68
dysphoria, 73
Rowe's personal construct therapy and,
106, 107
Anger Inventory, 67, 72
Angina, symptom interpretation and, 193
Anhedonia, psychotherapy and, 164
Antidepressant medication
depressive beliefs and, 90, 97
Rowe's personal construct therapy and
104
Antihypertensive medication, symptom
interpretation and, 197
Anxiety
adjustment to illness and, 205-207, 211
child abuse and, 243, 254
depression, self-worth contingencies
and, 116
269
Index
270
depressive beliefs and, 8 9
psychotherapy and
maladaptive schemata, 1 7 0 , 1 7 1
mood-congruent cognitions, 1 7 0
rational-emotive model and
assessment, 6 9 - 7 1
discriminant validity, 6 6 - 6 8
dysphoria, 7 2
laboratory stressors, 7 4 - 7 6
therapeutic change, 8 0
states of mind and, 3 0
cognitive content-specificity, 4 8
internal dialogue of conflict, 2 6
negative dialogue, 2 5
polarity, 6 , 8 - 1 0
positive dialogue, 4 2
test, see Test anxiety
validity issues, 4 4
Approach-avoidance, states of mind and, 5
Arbitrary inference
cognitive errors and, 9 4
depressive beliefs and, 9 0 , 9 2 , 9 7
Arousal
causal attributions in health and
illness and
motivation, 1 8 8
symptom interpretation, 1 9 8
child abuse and, 2 4 5 , 2 4 7
psychotherapy and
emotion, 1 5 6
emotional synthesis, 1 6 0
maladaptive schemata, 1 7 0
rational-emotive model and, 7 3 , 7 6
distress, 6 4 , 6 6 , 7 5 , 8 1 , 8 2
Arthritis, causal attributions and, 2 2 0
Assertion, depression, self-worth
contingencies and, 1 1 6 , 1 3 4 , 1 3 5 , 1 3 8
Assertion Inventory, depression and, 1 3 4
Assertiveness
maladaptive cognitions and, 1 6 8
rational-emotive model and, 7 2
states of mind and, 2 , 3 0
negative dialogue, 2 4
polarity, 7 , 9
positive dialogue, 2 2
positive monologue, 2 7
psychotherapy, 5 1
situational determinants, 4 7
Associative network models
cognitive psychology and, 1 5 2 - 1 5 4
integrative theory and, 1 5 5 , 1 5 6
maladaptive schemata and, 1 7 1
Asymmetry, states of mind and, 2 - 4 , 5 5
negative dialogue, 2 3 , 2 4
negative monologue, 2 8 , 2 9
positive dialogue, 2 1 - 2 3 , 4 0
positive monologue, 2 6 , 2 8
Attention
child abuse and, 2 4 9
cognitive distortions, 2 4 4
intervention, 2 6 0
psychotherapy and
cognitive psychology, 1 5 4
maladaptive cognitions, 1 6 7
Attention, self-focused, depression and,
1 3 5,
1 3 6
Attitudes, adjustment to illness and, 2 2 1
Attribution-labeling hypothesis, symptom
interpretation and, 1 9 6
Augmentation principle
causal attributions in health and
illness, 1 8 4
symptom interpretation and, 1 9 7 , 1 9 8
Automatic thought, psychotherapy and
maladaptive cognitions, 1 6 7
mood, 1 6 9
Automatic Thoughts Questionnaire, 1 0
Autonomic reactions
cognitive psychology and, 1 5 4 , 1 5 5
emotional synthesis and, 1 6 0
Avoidance
psychotherapy and, 1 7 0 , 1 7 1
recovery and, 1 9 1
Β
Balance, states of mind and, 3 , 4 , 1 7 , 2 0 ,
54,
5 5
cultural factors, 5 0
developmental factors, 5 0
information processing, 5 3 , 5 4
internal dialogue of conflict, 2 5
polarity, 4 , 5 , 1 0 , 1 1
positive dialogue, 2 1 , 2 2 , 4 0
positive monologue, 2 6
psychotherapy,52
set points, 4 5
temporal stability, 4 9
Beck Depression Inventory
child abuse and, 2 4 5 , 2 5 0 , 2 5 7
self-worth contingencies and, 1 2 5
environment, 1 2 9
Index
271
etiology, 1 2 4 , 1 2 5
self-schema content, 1 3 0
states of mind and, 4 4
Beck's cognitive therapy, depression and,
8 9 - 9 2 ,
9 6 ,
9 7
cognitive errors, 9 4 , 9 5
cognitive triad, 9 2 , 9 3
critical appraisal of, 9 8 - 1 0 3
development of depression, 9 5 , 9 6
effectiveness, 9 7 , 9 8
psychotherapy, 1 6 9
Rowe's personal construct therapy, 1 0 5 ,
1 0 8
schema, 9 3 , 9 4
Behavior
causal attributions in health and illness
and
adjustment, 2 0 5 , 2 2 1
health interventions, 2 2 4 , 2 2 5
recovery, 1 9 2
research methods, 2 2 0
theoretical implications, 2 1 9
psychotherapy and
cognitive psychology, 1 4 9 , 1 5 0
emotion, 1 6 3
Behavior modification, child abuse and,
2 4 0,
2 5 7
Behavioral rehearsal, states of mind and, 5 1
Beliefs
causal attributions in health and illness
and
intervention, 2 2 3 , 2 2 4
recovery, 1 9 2
symptom interpretation, 1 9 3 , 1 9 4 ,
1 9 7,
1 9 9
emotion and, 1 4 5
Bern's Sex Role Inventory, states of mind
and, 4 9
Bias, see also Negativity bias; Positivity bias
causal attributions in health and illness
and
adjustment, 2 0 5
motivational, 1 8 4
child abuse and, 2 3 9
cognitive-behavioral assessment, 2 5 3
social desirability, 2 5 1
maladaptive self-schema and, 1 6 8
Bidimensional assessment, states of mind
and, 1 0 , 1 1
Bidirectional causality, health and illness
and, 2 1 9
Bioenergetics, psychotherapy and, 1 6 5
Biological influences
causal attributions in health and illness
and
motivation, 1 8 9
primary prevention, 1 9 0
psychotherapy and, 1 7 2
cognitive psychology, 1 5 0
emotion, 1 6 1 , 1 6 3
emotional synthesis, 1 5 9 , 1 6 1
maladaptive cognitions, 1 6 7
Breast cancer, causal attributions and
adjustment, 2 0 0 , 2 0 6 , 2 0 7 , 2 1 1
interventions, 2 2 5
other-blame, 2 1 5
recovery, 1 9 2
self-blame, 2 1 3
Busse Durke Anger Inventory, child
abuse and, 2 5 2
C
California Personality Inventory, child
abuse a n d , 2 4 5
Cancer, causal attributions and, see also
Breast cancer; Lung cancer
adjustment, 2 0 1 , 2 0 3 , 2 0 4 , 2 0 7 , 2 0 8 ,
2 1 0,
2 1 1
chance, 2 1 7
control, 2 1 4
health interventions, 2 2 3
primary prevention, 1 8 9
self-blame, 2 1 2 , 2 1 3
symptom interpretation, 1 9 5
Cardiac bypass surgery, causal
attributions and
recovery, 1 9 1
symptom interpretation, 1 9 5
Cardiovascular functioning, causal
attributions and, 1 8 8
Causal attributions, health and illness
and,
1 7 9 - 1 8 2
adjustment
antecedents of, 2 0 0 - 2 0 4
chance, 2 1 6 , 2 1 7
consequences of, 2 0 4 - 2 0 9 ,
control, 2 1 3 - 2 1 5
environment, 2 1 6
other-blame, 2 1 5 , 2 1 6
self-blame, 2 0 9 - 2 1 3
2 1 7
Index
272
beliefs, 183, 184
consequences, 184, 185
information processing, 182, 183
intervention, 2 2 2 - 2 2 7
mediators, 185, 186
motivation, 184, 1 8 7 - 1 8 9
prevention, 1 8 6 - 1 9 3
recovery, 186, 1 9 1 - 1 9 3
research methods, 220-222
theoretical progress, 218, 219
Causal expectations, beliefs and, 183
motivation, 188
recovery, 192
symptom interpretation, 195
Causal schema, beliefs and, 183
Causal stability, attributions and, 185, 190
Causal suppositions, beliefs and, 183
Causality, states of mind and, 7, 8
Chemotherapy, recovery and, 192
Child abuse, 2 3 7 - 2 4 1 , 260, 261
child and, 2 4 6 - 2 5 0
cognitive-behavioral assessment, 250,
251
of child, 2 5 3 - 2 5 5
of family interaction, 251-253
cognitive distortions, 244, 245
coping, 241, 242
impulse control, 245
intervention, 255, 256
with child, 259, 260
with parent, 2 5 6 - 2 5 9
parenting skills, 243
social competency, 242, 243
Classical conditioning, maladaptive
schemata and, 171
Cognition and Reality, 151
Cognitive-affective set point, states of
mind and, 17, 20
Cognitive-affective system,
psychotherapy and, 159, 161, 166, 170,
171
Cognitive-behavioral model of emotion,
145, 146
Cognitive-behavioral therapy, causal
attributions in health and illness and,
224-227
Cognitive distortions, child abuse and,
244, 245, 260
Cognitive dysfunctions, child abuse and
intervention, 258, 260
parents, 241
Cognitive errors, Beck's cognitive therapy
and, 92, 94, 97, 101
Cognitive psychology, 146, 147
associative network models, 151-154
ecological validity, 1 4 8 - 1 5 1
information processing, 1 4 7 - 1 5 1
mainstream, see Mainstream cognitive
psychology
schema models, 151, 154, 155
unconscious information processing, 152
Cognitive-Somatic Anxiety Scale, 66
Cognitive therapy, Beck's, see Beck's
cognitive therapy
Cognitive triad, depressive beliefs and,
92, 93
Cognitive vulnerability, depression and,
123, 124
Collaborative empiricism
causal attributions in health and illness
and, 226
depressive beliefs and, 96, 112
Compliance
child abuse and, 255
illness and,
adjustment, 205, 215
recovery, 191, 192
symptom interpretation, 198, 199
Compulsivity, child abuse and, 243, 248
Computer analogy, psychotherapy and,
146, 147, 149, 153
Conflict Resolution Scale, depression and,
134
Congruent content, depression and, 120,
121
Consensus, causal attributions, illness
and, 183
Consistency
causal attributions, illness and, 183, 227
depression and, 1 1 9 - 1 2 1
Consolidation, depression and
causality, 121
self-schema, 1 1 9 - 1 2 1 , 130, 132
self-worth contingencies, 125
Content, states of mind and, 8, 9
Control, causal attributions, illness and,
185
adjustment, 202, 206, 2 1 3 - 2 1 5
chance, 217
intervention, 225
locus of, 188, 189
research methods, 222
Index
273
self-blame, 213
Controllability, causal attributions, illness
and
adjustment, 208, 215
recovery, 192
research methods, 220
intervention, 223
self-blame, 215
Cooperation, recovery and, 191
Coping
child abuse and
family interaction, 252
parents, 241, 242
depression and
assertion difficulties, 135
downward spiral, 136
self-focused attention, 135, 136
treatment, 138
illness, causal attributions and
adjustment, 205, 206, 210, 221
control, 214
environment, 216
other-blame, 215, 216
self-blame, 212
psychotherapy and, 167
states of mind and, 2, 4, 20
internal dialogue of conflict, 26
negative monologue, 28
polarity, 6, 7, 9-11
positive dialogue, 21- 23
Covariation principle, illness, causal
attributions and, 183
Culture, illness and
adjustment, 203
symptom interpretation, 194
Cybernetic theory, states of mind and, 4,
15,20
D
Defenses, psychotherapy and, 165
Delusions, states of mind and, 28
Demographics
adjustment to illness and, 204
child abuse and, 239, 246
coping, 241
intervention, 255
Denial
child abuse and, 255
illness and
adjustment, 205
recovery, 191
symptom interpretation, 197, 199
states of mind and
inner speechlessness, 29
negative monologue, 28
positive monologue, 26, 27
Dependency, depression and
Rowe's personal construct therapy, 108
self-worth contingencies, 127
Depression
Beck's cognitive therapy for, see Beck's
cognitive therapy
child abuse and, 258
dysfunctional attitudes and, 116, 117,
121, 138, 139
etiology, 138, 139
assertion difficulties, 134
causality, 121-123
cognitive vulnerability, 123
contractual contingencies, 124, 125
environment, 129
self-schema, 131
illness and
adjustment, 205-208, 211, 217
intervention, 222, 226
research methods, 220
psychotherapy and
mood,169
motivation, 164
rational-emotive model and
discriminant validity, 66-68
dysphoria, 72, 73
therapeutic change, 80
Rowe's personal construct therapy for,
see Rowe's personal construct therapy
self-schema model and, 117, 118
consolidation distinctions, 119-121
content distinctions, 119
self-worth contingency model and,
125-128
assertion difficulties, 134, 135
coping,133
downward spiral, 136
environment, 128, 129
maintenance, 135
remission, 136 -138
self-focused attention, 135, 136
self-schema consolidation, 132
self-schema content, 129-131
treatment, 137, 138
states of mind and, 30
Index
274
cognitive content specificity, 4 8
information
processing,
information processing,
processing, 555333,,, 555444
information
internal dialogue of conflict, 2 6
negative dialogue, 2 4
negative monologue, 2 8
polarity, 6 - 8
positive dialogue, 4 2
situational determinants, 4 7 , 4 8
temporal stability, 4 9
validity issues, 4 4
Depression Inventory, 6 7 , 7 2
Depressogenic schémas, depressive
beliefs and, 1 0 1
Desensitization, maladaptive schemata
and, 1 7 1
Desynchrony, states of mind and, 5 1
Developmental analysis, child abuse and,
2 5 0
Developmental delays, child abuse and,
2 4 7,
2 5 4 ,
2 5 9
Deviance, child abuse and, 2 4 2
Diabetes, causal attributions and
control, 2 1 4
environment, 2 1 6
self-blame, 2 1 2 , 2 1 3
symptom interpretation, 1 9 5
Diet, illness and
adjustment, 2 0 8
recovery, 1 9 2
Discipline, child abuse and, 2 4 3 , 2 4 4 , 2 5 1
Discounting principle, beliefs and, 1 8 3
Discriminant validity, rational-emotive
model and, 6 6 - 6 9 , 7 2 , 8 0
Distortion
Beck's cognitive therapy and, 9 6
cognitive errors, 9 4
cognitive triad, 9 3
schémas, 1 0 1
Rowe's personal construct therapy and,
laboratory stressors, 7 6
life events, 7 7 , 7 8
therapeutic change, 7 9 , 8 0
Downward spiral, depression and, 1 3 6
Drug treatment, depressive beliefs and, 9 8
DSM-III diagnoses, rational-emotive
model and, 7 2
Dysfunctional attitudes
depression and, see Depression
psychotherapy and, 1 6 5
Dysfunctional Attitudes Scale
depression and
environment, 1 2 9
etiology, 1 2 3 , 1 2 4
remission, 1 3 7
self-schema content, 1 3 0
self-worth contingencies, 1 2 5
treatment, 1 3 8
states of mind and, 1 0
Dysfunctional Attitudes ScaleContractual Contingencies Scale, 1 2 4 ,
1 2 5,
1 2 9
Dysfunctional attributions, illness and, 2 2 7
Dysfunctional beliefs
depression and, 9 0 , 9 6 , 1 1 2
illness and, 2 2 4
psychotherapy and, 1 6 4
Dysfunctional cognitions, depression
etiology and, 1 2 1 - 1 2 5
Dysfunctional states of mind
bidimensional assessment and, 4 6
set point, 4 0 - 4 5
situational determinants, 4 7
Dysphoria
rational-emotive model and, 6 7 , 7 1 - 7 3 ,
78,
8 0 ,
8 1
self-worth contingencies and, 1 1 6
Ε
1 0 3
Distraction, cognitive therapy and, 1 1 3
Distress
child abuse and, 2 4 9
illness and
adjustment, 2 1 6
intervention, 2 2 2
psychotherapy and, 1 5 9
rational-emotive model and, 6 4 , 8 1 , 8 3
discriminant validity, 6 6 - 6 8
dysphoria, 7 2
experimental manipulation, 7 3
Emotion
psychotherapy and, 1 4 4 , 1 6 1 , 1 6 2 , 1 7 2 ,
1 7 3
cognitive psychology, 1 4 6 , 1 4 7 , 1 4 9 ,
1 5 2,
1 5 4 ,
1 5 5
integrative theory, 1 5 6 - 1 6 1
maladaptive cognitions, 1 6 6 - 1 6 9
maladaptive schemata, 1 7 0 - 1 7 2
mood-congruent behavior, 1 6 9 , 1 7 0
motivator of change, 1 6 2 - 1 6 6
Index
275
states of mind and, 6
Emotional dysfunction, rational-emotive
model of, 63
Emotional synthesis, psychotherapy and,
159, 1 6 3 - 1 6 6
Endorsement inventories, states of mind
and, 44
Environment
child abuse and, 250
depression etiology and, 128, 129
illness, causal attributions and
adjustment, 208, 210, 216
intervention, 224
symptom interpretation, 193, 194,
197, 199
psychotherapy and
cognitive psychology, 1 4 8 - 1 5 1
emotional synthesis, 159, 160
motivation, 164
Equilibrium, states of mind and, 20, 22
Evolution, cognitive psychology and, 149,
depression and, 129
psychotherapy and
facial, 157
somatic, 165
states of mind and, 49
Focusing, psychotherapy and, 165
Food choices, causal attributions in
health and illness and
intervention, 222
motivation, 189
Foster care services, child abuse and, 238,
240, 259
Free association
depressive beliefs and, 91
states of mind and, 44, 53
Free recall, states of mind and, 44
Freud, depressive beliefs and, 91
Frustration, child abuse and, 2 4 5 - 2 4 7
Function, states of mind and, 8, 9
Functional impact, states of mind and, 7
Functional states of mind, 40, 41
150
Exercise, illness and
prevention, 186
recovery, 192
Expectancies, illness and, 184, 185
intervention, 226
research methods, 220
Expectancy-value model, illness and
motivation, 187, 188
prevention, 189
symptom interpretation, 195
Expectations, illness and, 187, 188
F
Facial expression, emotion and, 157, 158
Families, child abuse and, 2 3 9 - 2 4 1 , 254
impulse control, 245
interaction, assessment of, 2 5 1 - 2 5 3
intervention, 256
Fatigue, causal attributions and, 195, 199
Fear
child abuse and, 248, 254
illness, adjustment and, 206
psychotherapy and
emotion, 157, 159
maladaptive schemata, 171
Fear of Negative Evaluation Scale, 66, 76
Feedback
child abuse and, 242
G
Generalizability, cognitive psychology
and, 154
Generalization
child abuse and, 2 5 7 - 2 5 9
rational-emotive model and, 67, 75,
77
Generalized expectancies, illness and,
188, 189
Gestalt therapy
maladaptive cognitions and, 167
motivation and, 164, 165
Global Adjustment to Illness Scale, 206
Golden dialogue, see Positive dialogue
Golden mean, states of mind and, 4, 55
negative monologue, 29
positive monologue, 28
Golden section hypothesis, states of mind
and, 4, 1 1 - 1 3 , 17, 20, 55
bidimensional assessment, 47
cultural factors, 50
developmental factors, 50
internal dialogue of conflict, 25
negative dialogue, 24, 25, 43
positive dialogue, 21, 40, 42
positive monologue, 26
theoretical explanations, 1 3 - 1 5
Grandiosity, states of mind and, 26
Index
276
Guilt
depression and, 1 1 6
depressive beliefs and, 9 1
illness and, 1 8 2 , 2 0 1 , 2 0 9 , 2 1 0 , 2 1 7
psychotherapy and, 1 5 9
H
Headache, symptom interpretation and,
1 9 4,
1 9 7
Health, causal attributions in, see Causal
attributions in health and illness
Health belief model, causal attributions
and, 1 8 7
Health interventions, causal attributions
and,
2 2 2 - 2 2 7
Heart disease, causal attributions and
adjustment, 2 0 4 , 2 1 0
control, 2 1 4
recovery, 1 9 1 , 1 9 2
self-blame, 2 1 2 , 2 1 3
symptom interpretation, 1 9 5 , 1 9 6
Hemodialysis, causal attributions and
adjustment, 2 0 6
control, 2 1 5
High blood pressure, causal attributions
and
motivation, 1 8 7
self-blame, 2 1 2
Holmes-Rahe Scale, child abuse and, 2 5 2
Homeostasis, states of mind and, 2 0
Hopelessness, self-worth contingencies
and, 1 1 6 , 1 1 8
Hostility
depressive beliefs and, 9 1
rational-emotive model and, 7 4
Hot cognition, psychotherapy and, see
Psychotherapy
Hyperactivity, child abuse and, 2 4 1 , 2 4 8
Hypertension, causal attributions and
self-blame, 2 1 2
symptom interpretation, 1 9 5 - 1 9 8
Hyperthyroidism, symptom interpretation
and, 1 9 7
Hypervigilance, abused children and, 2 4 8 ,
2 5 4
Hypnosis, psychotherapy and, 1 6 6
Hypochondria, symptom interpretation
and, 1 9 7
Hypomania, states of mind and, 2 6 , 4 2
Hypothesis testing, depressive beliefs and,
9 7,
1 1 3
I
Identity, child abuse and, 2 4 2
Ideology, child abuse and, 2 4 2
Illness, causal attributions and, see Causal
attributions
Imagery
child abuse and, 2 5 0
psychotherapy and, 1 6 6
Immaturity, child abuse and, 2 4 2 , 2 4 3
Implicit learning, cognitive psychology
and, 1 5 2
Implosive therapy, psychotherapy and, 1 7 1
Impulse control, child abuse and, 2 4 1 ,
2 4 5 ,
2 6 0
Impulsiveness, states of mind and, 2 6
Incongruity, states of mind and, 5 4 , 5 5
Inconsistency
child abuse and, 2 4 9
depression and, 1 2 0
Index of Well-Being score, 2 0 6
Inference, cognitive psychology and, 1 4 9 ,
1 5 0
Information processing
illness, causal attributions and, 1 8 0 ,
1 8 2,
1 8 3
motivation, 1 8 8
symptom interpretation, 1 9 9
theoretical implications, 2 1 8
psychotherapy and, 1 4 4 , 1 5 4 , 1 7 2
cognitive psychology, 1 4 7 - 1 5 1
emotion, 1 6 1
emotional synthesis, 1 5 9 , 1 6 1
integrative theory, 1 5 5 , 1 5 6
maladaptive cognitions, 1 6 8
maladaptive schemata, 1 7 1
mood-congruent cognitions, 1 6 9
unconscious, 1 5 2 , 1 5 4 - 1 5 6 , 1 5 9 ,
1 6 0
rational-emotive model and, 7 1 , 8 3
states of mind and, 3 , 4 , 1 7 , 2 0
Golden section hypothesis, 1 4
inner speechlessness, 2 9 , 3 0
modes of, 5 2 - 5 4
negative dialogue, 2 3 , 2 4
negative monologue, 2 8
positive monologue, 2 7
Index
Inner speechlessness, states of mind and,
17
definition, 29
formulation, 29, 30
Insight-oriented therapy, child abuse and,
240
Insomnia, symptom interpretation and,
198
Intentionality, child abuse and, 239, 244
Internal dialogue, states of mind
and, 4
information processing, 52
polarity, 6, 7
self-statements, 15, 16
Internal dialogue of conflict, states of
mind and, 1 6 - 2 1
definition, 25
formulation, 25, 26
information processing, 54
negative monologue, 28
psychotherapy, 51, 52
set point, 43, 44
situational determinants, 47
Internality, illness and, 185
intervention, 225
motivation, 187
prevention, 190
recovery, 192
Intervention
child abuse and, 2 5 5 - 2 6 0
health, see Health interventions
Intimacy, psychotherapy and, 170
Irrational beliefs
arousal of distress and
dysphoria, 7 1 - 7 3
experimental manipulation, 73, 74
laboratory stressors, 7 4 - 7 6
life events, 77, 78
assessment of, 65, 66
discriminant validity, 6 6 - 6 9
new developments, 6 9 - 7 1
depression and, 123, 132
therapeutic change and, 7 9 - 8 1
Irrational Beliefs Test
assessment, 69, 71
discriminant validity, 6 5 - 6 9
dysphoria, 72, 73
experimental manipulation, 74
laboratory stressors, 7 4 - 7 6
Irrational thinking, emotion and, 145
277
Irrationality, rational-emotive model and,
64
Isolation, see also Self-isolation
child abuse and, 248
child, 246
cognitive distortions, 244
intervention, 258
social competency, 242
Rowe's personal construct therapy and,
104
J
Just World scale, adjustment to illness
and, 216
L
Labeling, child abuse and, 253
Language delays, child abuse and, 247,
248, 254, 259
Learned helplessness
illness and, 184
prevention, 191
theoretical implications, 218
self-worth contingencies and, 116
Legal system, child abuse and, 239
Leukemia, adjustment and, 210
Lifestyle changes, illness and
adjustment, 205
intervention, 225
motivation, 188
recovery, 192
Locke Wallace Test, child abuse and, 252
Locus of control, motivation and, 188, 189
Logic, psychotherapy and
emotion, 145, 146
maladaptive cognitions, 167, 168
Loneliness
causal attributions and, 184
psychotherapy and, 157
Rowe's personal construct therapy and,
109
Lopsided constructs, states of mind and
cultural factors, 50
developmental factors, 50
negative monologue, 28
positive dialogue, 21, 22
positive monologue, 26
Lung cancer, adjustment and, 200
Index
278
M
Magnification, depressive beliefs and, 1 0 2
Mainstream cognitive psychology, 1 4 6 ,
1 4 7,
1 5 0
Maladaptive cognitions, psychotherapy
and,
1 6 6 - 1 6 9
Mania, states of mind and, 2 6 , 2 7
cognitive content-specificity, 4 8
positive dialogue, 4 2
Manifest Anxiety Scale, 6 7 , 7 2
Marital relationship, child abuse and
coping, 2 4 1
family interactions, 2 5 1
social competency, 2 4 2
Mass media presentations, illness and
interventions, 2 2 1 , 2 2 3
symptom interpretation, 1 9 4
Means-ends thinking, child abuse and,
2 5 0,
2 5 2
Mediators, illness, causal attributions
and, 1 8 2 , 1 8 5 , 1 8 6
adjustment, 2 0 2 , 2 1 7
control, 2 1 4
experiments, 2 2 1
intervention, 2 2 5 , 2 2 6
motivation, 1 8 7 , 1 8 8
other-blame, 2 1 5 , 2 1 6
prevention, 1 9 0
research methods, 2 2 0
self-blame, 2 1 3
theoretical implications, 2 1 8
Medical regimens, complicance with, 1 9 8 ,
2 1 5
Medical sociology, symptom
interpretation and, 1 9 7
Melancholia, psychotherapy and, 1 6 4
Memory
depression and, 1 1 7 , 1 1 8
psychotherapy and
associative network models, 1 5 3 , 1 5 4
cognitive psychology, 1 4 9
emotional synthesis, 1 6 0 , 1 6 1 , 1 6 3
integrative theory, 1 5 5
maladaptive schemata, 1 7 2
mood-congruent cognitions, 1 6 9
motivation, 1 6 6
schema models, 1 5 4 , 1 5 5
states of mind and, 3
information processing, 5 3 , 5 4
polarity, 6
Mental retardation, child abuse and, 2 4 7
Metaphysical beliefs, Rowe's personal
construct therapy and, 1 0 5 - 1 0 7 , 1 1 0 ,
1 1 2,
1 1 3
Metapsychology, motivation and, 1 6 5
Metatheoretical perspectives,
psychotherapy and, 1 4 4 , 1 7 2
cognitive psychology, 1 4 7 , 1 4 9
emotion, 1 1 6
integrative theory, 1 0 6
Mindlessness, states of mind and, 2 9 , 3 0
Minimization, depressive beliefs and, 9 4
Misattribution paradigm, symptom
interpretation and, 1 9 9
Modeling
child abuse and, 2 4 6 , 2 5 7
cognitive psychology and, 1 4 7 , 1 5 0
Rowe's personal construct therapy and,
1 0 8,
1 1 3
Moderation, states of mind and, 2 3
Mood
child abuse and, 2 4 4
depressive beliefs and, 9 6 , 9 9 , 1 1 1 - 1 1 3
illness, adjustment and, 2 1 1
states of mind and, 9
Mood-congruent cognitions,
psychotherapy and, 1 6 9 , 1 7 0 , 1 7 3
Motivation
child abuse and, 2 5 0
family interactions, 2 5 1 , 2 5 2
intervention, 2 5 5
illness, causal attributions and, 1 8 4 - 1 8 7
adjustment, 2 0 0 , 2 0 2 , 2 0 3 , 2 0 5
health belief model, 1 8 7
intervention, 2 2 2 , 2 2 4 , 2 2 6
prevention, 1 9 0
recovery, 1 9 1 , 1 9 2
research methods, 2 2 0
social learning model, 1 8 7
symptom interpretation, 1 9 5 , 1 9 7 , 1 9 9
theoretical implications, 2 1 8 , 2 1 9
psychotherapy and
cognitive psychology, 1 5 0
emotion, 1 6 3
unconscious, 1 5 2
Multidimensional scaling
illness, adjustment and, 2 0 8
rational-emotive model and, 6 9
Muscular tension, emotion and, 1 5 8
Index
279
Myocardial infarction, causal attributions
and
adjustment, 201, 203, 204, 207 -209, 211
chance, 216
control, 214
other-blame, 215
recovery, 192
symptom interpretation, 199
N
Narcissism, child abuse and, 242
Narcissistic vulnerability, depression and,
127, 129
Natural selection, psychotherapy and, 156
Negative affect
child abuse and, 246
depression and, 135
Negative automatic thoughts, depressive
beliefs and, 90, 97
Negative dialogue, states of mind and,
17-19,21
cognitive content-specificity, 48
definition, 23
formulation, 23-25
information processing, 54
negative monologue, 28
psychotherapy, 51
situational determinants, 48
temporal stability, 49
Negative life events, depression etiology
and,121-125
Negative monologue, states of mind and,
17-19,21
definition, 28
formulation, 28, 29
positive monologue, 26
psychotherapy, 51, 52
situational determinants, 48
Negative self-statements
psychotherapy and, 167, 171
rational-emotive model and, 74, 75
states of mind and, 2, 16
information processing, 53
inner speechlessness, 29
internal dialogue of conflict, 25
negative dialogue, 23
negative monologue, 28
polarity, 7, 9
positive dialogue, 21, 22
Negative strikingness asymmetry, states
of mind and, 3
Negative thoughts, depressive beliefs and,
91,99,111-113
cognitive errors, 95
cognitive triad, 93
schemas,94
Negativity bias, states of mind and, 2, 3, 14
Neglect, child abuse and, 238, 247, 249,
250, 261
cognitive distortions, 244
coping, 241
family interactions, 252
impulse control, 245
intervention, 255, 256, 258, 259
parenting skills, 243
Neurological substrate, psychotherapy
and, 159
Neuroses, states of mind and, 48
Neuroticism, rational-emotive model and,
67,72,73,78,80
Neurotransmission, states of mind and, 5
Nervousness, symptom interpretation
and, 197
Noncompliance
child abuse and, 243, 249, 255
symptom interpretation and, 198, 199
Nonverbal behavior, psychotherapy and
emotion, 157, 158
maladaptive cognitions, 167
o
Obsessional traits, states of mind and, 26
Operant learning, states of mind and, 6
Optimism, states of mind and, 26, 46
Overgeneralization, depressive beliefs
and, 90,92,97
cognitive errors, 94
schemas, 101, 102
p
Pain, symptom interpretation and, 198, 199
Paradoxical intention therapy, states of
mind and, 51
Parents
child abuse and, 238 - 240
cognitive distortions, 244, 245
Index
280
coping, 241, 242
impulse control, 245
skills, 243, 244
social competency, 242, 243
depression and, 132
Patterson coding system, child abuse and,
257
Peabody Picture Vocabulary Test, child
abuse and, 247
Peers, child abuse and, 254, 259
Penetrance, states of mind and, 13
Perception
illness and, 185
intervention, 225
research methods, 220
psychotherapy and, 172
cognitive psychology, 148-151
emotion, 158, 159, 161, 162
emotional synthesis, 159
maladaptive schemata, 172
subliminal, 152
Perceptual-motor processing,
psychotherapy and
emotion, 158, 163
emotional synthesis, 160
motivation, 166
Perfectionism, depression and, 134
Personal construct therapy, see Rowe's
personal construct therapy
Personal contracts, Rowe's personal
construct therapy and, 108, 109
Personality
child abuse and, 239
family interaction, 252
social competency, 242
illness, causal attributions and
adjustment, 201, 211
interventions, 223
prevention, 189
self-blame, 212, 213
symptom interpretation, 194, 197
Personalization, depressive beliefs and, 95
Placebo, symptom interpretation and, 199
Polarity, states of mind and, 4-6
bidimensional assessment, 10, 11
conceptual issues, 7 - 9
in internal dialogue, 6, 7
Pollyanna principle, states of mind and, 3,
26-29
Positive dialogue, states of mind and, 16,
18,19,21,55
cognitive content-specificity, 48
cultural factors, 50
definition, 21
developmental factors, 50
formulation, 21, 23
internal dialogue of conflict, 26
negative dialogue, 23, 24
positive monologue, 27
psychotherapy, 52
set points, 40-44
situational determinants, 47,48
temporal stability, 49
Positive monologue, states of mind and,
17-19,21
cognitive content-specificity, 48
definition, 26
formulation, 26-28
psychotherapy, 52
situational determinants, 47, 48
Positive self-statements
psychotherapy and, 167
states of mind and
information processing, 53
inner speechlessness, 29
internal dialogue of conflict, 25
negative dialogue, 23
negative monologue, 28
polarity, 7, 9
positive dialogue, 21, 22
positive monologue, 26
Positivity bias, states of mind and, 3, 14
Preattentive level, psychotherapy and,
155, 156, 161
Prematurity, child abuse and, 246, 247
Prevention, illness and, 186, 195
health intervention, 223
motivation, 187
primary, 189-191
secondary, 191-193
theoretical implications, 218
Profile of Mood States, adjustment to
illness and, 206
Proportions, states of mind and
cultural factors, 49, 50
developmental factors, 49, 50
group contrast studies, 31-36
information processing, 53
negative dialogue, 23, 24
negative monologue, 28
positive dialogue, 23, 42
positive monologue, 26
281
Index
psychotherapy outcome studies, 37 - 39
situational determinants, 48
temporal stability, 49
validity issue, 44
Psychoanalysis, depressive beliefs and,
90-92
Psychoanalytic theory, emotion and, 162,
165
Psychodynamic psychotherapy,
depressive beliefs and, 97
Psychodynamic theories, child abuse and,
238,244
Psychodynamics, states of mind and, 5
Psycholinguistics, states of mind and, 6
Psychometric evaluation, irrational
beliefs and, 65, 66
Psychopathology
child abuse and, 239
depressive beliefs and, 92
states of mind and
bidimensional assessment, 47
cognitive content-specificity, 48
negative monologue, 28
polarity, 10
Psychosis, child abuse and, 238, 239
Psychotherapy
child abuse and, 240, 259
hot cognition and, 144, 172, 173
cognitive-behavioral model, 145, 146
cognitive psychology, 146-155
emotion, 161-172
integrative theory, 155-161
rational-emotive model 63,64,82
states of mind and, 30, 37 -39,47,51,52
Psychotropic medication, motivation and,
164
Punishment, child abuse and, 246, 248
cognitive distortions, 244
family interaction, 251
intervention, 260
R
Race, child abuse and, 253
Rational Behavior Inventory
discriminant validity, 65 - 68
dysphoria, 72
life events, 77, 78
Rational beliefs, Rowe's personal
construct therapy and, 105-107, 110,
112,113
Rational-emotive model, 63 -65
arousal of distress
dysphoria, 71-73
experimental manipulation, 73, 74
laboratory stressors, 74- 76
life events, 77, 78
irrational beliefs and, 65, 66,
discriminant validity, 66-69
new developments, 69-71
therapeutic change, 79-81
Reactance theory, recovery and, 191
Reality, adjustment to illness and, 202, 203
Reality testing
depressive beliefs and, 97, 113
psychotherapy and, 168
Recall
depression and, 117, 119, 120, 130, 131
rational-emotive model and, 70
Reciprocal determinism
cognitive psychology and, 150
emotion and, 145
Recovery behavior, 186, 191-193
adjustment and, 207, 211
intervention, 222
research methods, 220
symptom interpretation, 195
theoretical implications, 218, 219
Reinforcement
child abuse and, 246, 256, 257
illness and, 188, 189
states of mind and, 5
Rejection
depression and, 128
depressive beliefs and, 93, 112
psychotherapy and, 164
Relapse, prevention and, 190, 191'
Remission, depression and, 131, 136-138
Respiratory disorders, depression and, 92
Reverse placebo effect, 198
Role models, child abuse and, 245, 256
Role play
child abuse and, 250, 257
psychotherapy and, 169
Role reversal, child abuse and, 244
Rowe's personal construct therapy, 103
alternative value systems and, 109-111
changing beliefs and, 107 -109
metaphysical beliefs and, 105-107
rational beliefs and, 105 -107
Rowe's model of depression and,
103-105
282
Index
S
Sadness
child abuse and, 2 4 9
depression and, 1 1 6
psychotherapy and, 1 6 7 - 1 6 9
Schema
depressive beliefs and, 9 2 - 9 6 , 1 0 1 - 1 0 3
illness, causal attributions and
beliefs, 1 8 3
health interventions, 2 2 5
symptom interpretation, 1 9 4 - 1 9 6
psychotherapy and
cognitive psychology, 1 5 1 , 1 5 4 , 1 5 5
emotional synthesis, 1 6 0 , 1 6 1
integrative theory, 1 5 6
maladaptive, 1 7 0 - 1 7 2
mood, 1 6 9
motivation, 1 6 5 , 1 6 6
Secondary gain, symptom interpretation
and, 1 9 7
Selective attention, cognitive psychology
and, 1 5 2
Selective forgetting, child abuse and, 2 5 1
Selective information seeking, illness and,
1 9 6,
1 9 7
Selective recall, depressive beliefs and, 9 2
Selective reinforcement, child abuse and,
2 4 6
Self-blame
depression and
self-focused attention, 1 3 5
treatment, 1 3 7 , 1 3 8
illness, causal attributions and
adjustment, 2 0 1 , 2 0 9 - 2 1 7 , 2 2 1
intervention, 2 2 2 , 2 2 3 , 2 2 5
recovery, 1 9 1
Self-consciousness
states of mind and, 1 6
symptom interpretation and, 1 9 4
Self-control
adjustment to illness and, 2 1 2
child abuse and, 2 5 0
Self-criticism
depression and, 1 2 7 , 1 3 4 - 1 3 6
depressive beliefs and, 1 0 2 , 1 1 2
psychotherapy and
maladaptive cognitions, 1 6 7 , 1 6 8
motivation, 1 6 4 , 1 6 5
Self-denial, depression and, 1 3 4
Self-efficacy, illness and, 1 8 5
motivation, 1 8 8
theoretical implications, 2 1 8 , 2 1 9
Self-esteem
child abuse and, 2 4 5 , 2 4 8
depression and, 1 1 6 , 1 2 7 , 1 3 5
illness and
adjustment, 2 0 0
beliefs, 1 8 4
motivation, 1 8 4
self-blame, 2 1 3
Self-evaluation, states of mind and, 6
Self-focused attention, depression and,
1 3 5,
1 3 6
Self-help, illness prevention and, 1 8 9 , 1 9 0
Self-isolation, self-worth contingencies
and, 1 3 8
Self-monitoring
child abuse and, 2 5 0 , 2 5 7
states of mind and, 2 7
Self-perception, states of mind and, 3
Self-rating, illness and
prevention, 1 9 0
recovery, 1 9 2
Self-reference, depression and, 1 1 7 - 1 2 0 ,
1 3 1 , 1 3 2
Self-regulation, illness and
symptom interpretation, 1 9 5 , 1 9 8
theoretical implications, 2 1 8
Self-report
child abuse and
coping, 2 4 1
family interactions, 2 5 1
illness, causal attributions and, 2 0 5 , 2 1 1
rational-emotive model and, 6 7 , 6 8 , 7 1 ,
72,
7 5 , 7 6 ,
7 9
Self-report inventories, irrational beliefs
and, 6 5
Self-schema
depression, self-worth contingencies
and, 1 2 5 , 1 2 6 , 1 3 8
consolidation, 1 3 2 , 1 3 8
content, 1 2 9 - 1 3 1 , 1 3 8
downward spiral, 1 3 6
maladaptive cognitions and, 1 6 8 , 1 6 9
states of mind and
cognitive content-specificity, 4 8
information processing, 5 3
negative dialogue, 2 4
polarity, 6
Self-schema model, depression and, 1 1 7 ,
1 1 8,
1 2 1 ,
1 3 9
283
Index
consolidation distinctions, 1 1 9 - 1 2 1
content distinctions, 119
Self-statement training, states of mind
and, 51, 52
Self-statements, see also Negative
self-statements; Positive self-statements
rational-emotive model and, 74, 76
states of mind and
internal dialogue, 15, 16
polarity, 6, 7
psychotherapy, 51
situational determinants, 47
Self-verbalization
rational-emotive model and, 73
states of mind and, 17
cognitive content specificity, 48
information processing, 53
polarity, 6
situational determinants, 47, 48
Self-worth contingencies, depression and,
1 2 5 - 1 2 8 , 138, 139
assertion difficulties, 134, 135
coping, 133
downward spiral, 136
environmental information, 128
maintenance, 135
remission, 136, 138
self-focused attention, 135, 136
self-schema consolidation, 132
self-schema content, 1 2 9 - 1 3 1
treatment, 137, 138
Semantic differential, states of mind and, 6
Semantic networks, psychotherapy and
cognitive psychology, 153
emotional synthesis, 161
integrative theory, 155
maladaptive schemata, 171
mood-congruerit cognitions, 171
Sensory motor schemata, emotion and,
158
Set points, states of mind and, 20, 24
cultural factors, 50
developmental factors, 50
dysfunctional, 4 1 - 4 3
internal dialogue of conflict, 25, 26
positive dialogue, 40, 41
positive monologue, 26
positive-negative continuum, 45, 46
psychotherapy, 52
temporal stability, 49
Severity, illness and, 187
Sex role identification, states of mind
and, 49, 50
Sick role behavior, 186
Skill relearning, child abuse and, 256
Smoking, causal attributions and
adjustment, 207, 208, 210
intervention, 223
motivation, 188, 189
other-blame, 215
prevention, 186, 1 8 9 - 1 9 1
recovery, 191, 192
self-blame, 212
Social Avoidance and Distress Scale,
rational-emotive model and, 70
Social competency, child abuse and, 242
Social desirability, child abuse and, 251,
254
Social distance, child abuse and, 252
Social Interaction Self-Statement Test, 49
Social isolation, child abuse and
child, 246
cognitive distortions, 244
intervention, 258
social competency, 242
Social learning theory
child abuse and, 246
illness and, 185, 1 8 7 - 1 8 9
Social skills deficits, child abuse and, 242,
252
Sociodemographic influences, illness and,
189, 203
Socioeconomic status
child abuse and, 240, 251
assessment of child, 253
coping, 241
intervention, 255
states of mind and, 50
Somatic changes, psychotherapy and, 166
Somatic complaints, depression and, 116
Somatic feedback, psychotherapy and, 165
Sophistication, adjustment to illness and,
203, 204
Speech delays, abused children and, 247,
248, 254, 259
Stability, illness and, 185
intervention, 225, 226
motivation, 187
prevention, 189, 190
Standardized inventories, child abuse
and, 250
Stanford Binet score, child abuse and, 247
Index
284
State-Trait Anxiety Inventory, 6 6 , 6 7
States of mind model, 1 6 - 2 1 , 5 5
clinical research directions
bidimensional assessment, 4 6 , 4 7
cognitive content specificity, 4 8
cultural factors, 4 9 - 5 1
developmental factors, 4 9 - 5 1
information processing modes, 5 2 - 5
psychotherapy, 5 1 , 5 2
set points, 4 5
temporal stability, 4 9
definition, 2 1 - 3 0
empirical evaluation, 3 0 - 4 0
set points, 4 0 - 4 3
validity issues, 4 3 , 4 4
internal dialogue, 1 5 , 1 6
Statistical moderation, rational-emotive
model and, 7 7
Stomachache, symptom interpretation
and, 1 9 4
Stress
child abuse and, 2 3 8 , 2 4 6 , 2 4 7
family interaction, 2 5 2
impulse control, 2 4 5
intervention, 2 5 8
parents, 2 4 1 , 2 4 2
depression and
coping, 1 3 3
environment, 1 2 9
self-focused attention, 1 3 5
self-schema consolidation, 1 3 2
self-worth contingencies, 1 2 8
treatment, 1 3 8
depressive beliefs and, 9 5
illness and
adjustment, 2 0 0 , 2 0 3 - 2 0 5 , 2 0 7 , 2 1 1
other-blame, 2 1 5
theoretical implications, 2 1 9
rational-emotive model
assessment, 7 0 , 7 1
discriminant validity, 6 8
laboratory stressors, 7 6
life events, 7 7 , 7 8
states of mind and, 4
coping, 2 1
inner speechlessness, 3 0
internal dialogue of conflict, 2 6
negative dialogue, 2 5
polarity, 6 , 7 , 9 , 1 1
Stress-innoculation training, depression
and, 1 3 7
4
Strikingness, states of mind and
Golden section hypothesis, 1 3 - 1 5
negative dialogue, 2 4
positive monologue, 2 7
Subliminal perception, cognitive
psychology and, 1 5 2
Suggestibility, psychotherapy and, 1 6 6
Suggestion hypothesis, symptom
interpretation and, 1 9 6
Support system, child abuse and, 2 4 2 , 2 4 3
Susceptibility, illness and, 1 8 7
Symmetry, states of mind and, 1 7 , 2 5
Symptom interpretation, causal
attributions and, 1 9 3 - 2 0 0
Systematic desensitization, child abuse
and, 2 5 6
Systemic theory, emotion and, 1 6 2 , 1 6 3
Τ
Tactical procedures, depressive beliefs
and, 9 6 , 9 7
Temporal stability, illness and, 1 8 5
intervention, 2 2 6
prevention, 1 8 9
Test anxiety
rational-emotive model and, 6 7 , 7 5
states of mind and, 6 , 2 2
Test Anxiety Inventory, 6 6
Therapeutic change, irrational beliefs
and, 7 9 - 8 1
Thiozide drug treatment, symptom
interpretation and, 1 9 6
Total Anxiety Scale, 6 7
Toxic shock syndrome, causal
attributions and, 1 9 4
Transcendental realism, cognitive
psychology and, 1 5 1
Type A behavior
illness, adjustment and, 2 0 4
rational-emotive model and, 6 9 , 7 9
symptom interpretation and, 1 9 4
Type C behavior, illness, adjustment and,
2 0 4
U
Unconscious information processing
cognitive psychology and, 1 5 2 , 1 5 4
emotional synthesis and, 1 5 9 , 1 6 0
integrative theory and, 1 5 5 , 1 5 6
Index
285
Unemployment, child abuse and, 241, 242
V
Vanity, Rowe's personal construct
therapy and, 107
Victimization, causal attributions and, see
also Accident victims
adjustment, 200-203, 207
control, 214, 215
other-blame, 216
self-blame, 212, 213
Violence, child abuse and, 245, 248
Vulnerability, see also Cognitive
vulnerability; Narcissistic vulnerability
depression and, 117
assertion diffiulties, 134, 135
environmental sensitivity, 129
remission, 136, 137
self-focused attention, 135
self-schema consolidation, 132
self-schema content, 130, 131
treatment, 138
depressive beliefs and, 95
psychotherapy and
emotion, 164
maladaptive cognitions, 168
motivation, 166
rational-emotive model and, 77
W
Withdrawl
child abuse and, 248, 249, 260
depression and, 116
Word association, cognitive psychology
and, 153
Y
Yang and Yin, states of mind and, 5, 11