Is the Black Dog Is the Black Dog Really a Dalmatian?Really a Dalmatian?

An investigation into whether Stress Impact and Attributional Style lead to different

outcomes in CBT for Depression

K. Good, Massey University, New ZealandP. Merrick, Massey University, New ZealandR. Fletcher, Massey University, New ZealandN. Kazantzis, La Trobe University, Australia

o Research topic

o Methodology• Measures• Defining variables• Multilevel analysis

o Results

o Discussion

OverviewOverview

To get you thinking....To get you thinking....

o Depression and CBT• What causes variation in client recovery?

o Stress-Diathesis Model

Stress Impact

Research GapsResearch Gaps

Depression

Diathesis

Context

StressLoad

Capacity

Chronicity

Financially-related

Type of stress

Bio

Psycho

Social

Attributional Style

Existing ResearchExisting Researcho Stress and Depression

• Lack of consensus on definition (and measures)• Transition to a dynamic, contextual relationship

o Attributional Style and Depression• Depressogenic attributional style• Need more clinical samples and change over

time

o Methodological Limitationso Mostly pre-post outcomeso Few studies examining multiple predictors

simultaneously

o Patients presenting with first-time depression

o 20 Sessions of CBT• Rigorous therapist training and supervision

• Strict homework protocol and measures

o Patient measures• Beck Depression Inventory (BDI-II)

• Every session

• Attributional Style Questionnaire (ASQ)• Intake, sessions 5, 8, 20 and follow-ups

• Stress Impact ?

Treatment Study ContextTreatment Study Context

• Definition?• Objective vs Subjective

measurement?• Frequency of measurement?

Measuring StressMeasuring Stress

Stage 1 Identifying Stressors

o Therapist Questionnaire

• List top 3 stressors & rate severity

• Rate each stressor on 5 dimensions:

• relationships• autonomy• finances• control• chronicity

• Guidelines & examples developed

• Reviewed by 4 Clinical Psychologists

o Impact of Event Scale (IES)• Client questionnaire about specific stressors • 15 items (8 avoidance, 7 intrusion)

o Application to my study:• Measured at 8 time points across therapy• 0 – 5 likert scale & an optional score of “Not Rated”• Anchors (language & affect)

o 3 phases of rating:

Training Rating Checking

Measuring StressMeasuring Stress

Stage 2 Measuring Stress Across Time

Measuring Stress - Measuring Stress - ReliabilityReliability

Inter-Rater Reliability

o Percentage Agreement:o 84% agreement across all training sessionso 100% agreement at the end of the training phaseo Different sessions & therapists used in the training

Item Analysis and Reliability of the Measure

o Item AnalysisIntrusion Items Avoidance Items

1 2 3 4 5 6 71 2 3 4 5 6 7 8

3 4 5 2 4 6 7

Initial Items

Final Items

Included

How to analyse the data?How to analyse the data?Depression severityo Raw data

Stress Impact

Attributional Style

o Level 1 (time variant) vs Level 2 (time invariant)?

o Clear patterns in patient improvement by session 10

• Rapid (> 66%)• Expected (33% – 66%)• Minimal (< 33%)

o Mostly depressive vs mostly not

o Data from first three measurements

Preliminary results show Preliminary results show there is clear variability in there is clear variability in the data...the data...

0  1 3, 5, 8, 92 1, 1, 3, 3, 4, 4, 5, 6, 8, 83 0, 2, 2, 3, 3, 7, 74 2, 3, 4, 6, 95 0, 3

0 8, 91 0, 1, 3, 4, 6, 8, 92 1, 1, 2, 4, 6, 63 2, 44 2, 65  

Intake BDI Scores

Rate of Change in BDI

• There is great variation among individuals• Clients vary both in their intake BDI scores

and also the rate of change they show through therapy

• Aggregating their data would neglect this variation

Building the Multilevel Building the Multilevel ModelModel

Model A

BDI

Model B

BDI Time

Model C

BDI Time Stress Curve

Model D

BDI Time Stress Curve

A-Style

```````````

• BDI vs BDI Cube Root?• Time vs Session Time?• StressCurve or Attributional Style entered first?• Stress as level 1 or level 2 (cut the data set)?

??

    Parameter Model A Model B Model C Model DFixed Effects            

Initial status, Intercept γ00 18.73*** 24.92***    

π0i     (1.82) (2.15)    

  Stress Curve γ01 -   -           -  -    

  Attributional Style γ02  -  -           -  -                 Rate of Change,          

π1i Intercept γ10  - -0.93***           - (0.10)    

  Stress Curve γ11  -  -           -  -    

  Attributional Style γ12  -  -           -  -                 Variance Components          

Level 1 Within-person σ2e 61.82*** 27.72*****    

      (3.91) (1.80)    

Level 2 In initial status σ20 83.11*** 116.41***    

      (23.89) (33.25)    

  In rate of change σ21  - 0.29*    

       - (0.12)    

  Covariance σe  - -4.65*          - (1.86)                 

Pseudo R2 statistics          and Goodness of Fit          

  R2e    - 55%    

  R20    -  -    

  R21    - -       Deviance   3,748.63 3,391.92      AIC   3,754.63 3,403.92      BIC   3,767.42 3,429.51    

Average patient had a significant change in depressive symptoms

Time explains 55% of within-patient variance

    Parameter Model A Model B Model C Model DFixed Effects            

Initial status, Intercept γoo 18.73*** 24.92*** 26.29***  

π0i     (1.82) (2.15) (4.30)  

  Stress Curve Leγ01 -   - -1.21         -  - (3.24)  

  Attributional Style Γ02  -  - -         -  -  -               Rate of Change,          

π1i Intercept γ10  - -0.93*** -.051**         - (0.10) (0.18)  

  Stress Curve γ11  -  - -0.36*         -  - (0.14)  

  Attributional Style γ12  -  - -         -  -  -  Variance Components           

Level 1 Within-person σ2e 61.82*** 27.72***** 27.70***  

      (3.91) (1.80) (1.80)  

Level 2 In initial status σ20 83.11*** 116.41*** 115.48***  

      (23.89) (33.25) (32.99)  

  In rate of change σ21  - 0.29* 0.16*  

       - (0.12) (0.06)  

  Covariance σe  - -4.65* -2.63*        - (1.86) (1.13)  

           Pseudo R2 statistics and Goodness of Fit          

  R2e    - 55% 55%  

  R20    -  - 1%  

  R21    - -  45%    Deviance   3,748.63 3,391.92 3,381.98    AIC   3,754.63 3,403.92 3,397.98    BIC   3,767.42 3,429.51 3,342.10  

Patients with different stress curves do not have significantly different intake BDIs or rates of change

Introducing only stress as a predictor doesn’t explain a significant amount of variance in the model

    Parameter Model A Model B Model C Model DFixed Effects            

Initial status, Intercept γoo 18.73*** 24.92*** 26.29*** 24.47***

Π0i     (1.82) (2.15) (4.30) (3.65)

  Stress Curve γ01 -   - -1.21 -4.75       -  - (3.24) (3.87)

  Attributional Style γ02  -  - - 12.79**       -  -  - (3.87)           Rate of Change,          

Π1i Intercept γ10  - -0.93*** -.051** -0.45*       - (0.10) (0.18) (0.17)

  Stress Curve γ11  -  - -0.36* -0.26       -  - (0.14) (0.14)

  Attributional Style γ12  -  - - -0.37       -  -  - (0.18)Variance Components          

Level 1 Within-person σ2e 61.82*** 27.72***** 27.70*** 27.70***

      (3.91) (1.80) (1.80) (1.80)

Level 2 In initial status σ20 83.11*** 116.41*** 115.48*** 80.23***

      (23.89) (33.25) (32.99) (23.25)

  In rate of change σ21  - 0.29* 0.16* 0.13

       - (0.12) (0.06) (0.05)

  Covariance σe  - -4.65* -2.63* -1.61      - (1.86) (1.13) (0.85)Pseudo R2 statistics           

and Goodness of Fit          

  R2e    - 55% 55% 55%

  R20    -  - 1% 31%

  R21    - -  45% 55%  Deviance   3,748.63 3,391.92 3,381.98 3,372.75  AIC   3,754.63 3,403.92 3,397.98 3,392.75  BIC   3,767.42 3,429.51 3,342.10 3,435.41

After controlling for attributional style, the difference in BDI rate of change for patients with different stress curves is significantly reduced

Taken together, stress and attributional style explain 45% of variability in BDI initial status and 55% of variability in BDI rate of change

Attributional Style moderates Attributional Style moderates the the

Stress-BDI relationshipStress-BDI relationship

Rap

id

Minimal Expected Rapid

BDI-II Improvement

Stress Improvement

Exp

ecte

dM

inim

al

A depressognic attributional

style slows the improvement in BDI-II caused by an improvement

in stress

Non-depressogenicDepressogenic

Preliminary Results Preliminary Results SuggestSuggest

Attributional Style (moderator)

Stress Impact Depression

(predictor)• Stress & BDI-II correlate best when clients have

non-depressogenic AS• When they have mostly depressogenic AS, stress

improvement is stunted – it doesn’t directly correspond to improved BDI-II scores

Post-Hoc AnalysesPost-Hoc AnalysesStressor Characteristicso Modal stressor: control, relationships, autonomy,

finances, sequenceo Impact on autonomy: therapy completion and

attributional styleo Impact on relationship: previous therapy; lower stress

at conclusiono Impact on finances: therapy completiono Controllability: previous therapyo Chronicity: less severe intake BDIo Severity: gender and children

Final model variableso Stress curve, attributional style, BDI intake severity,

gender, therapy completion, marital status

Final Multilevel ModelFinal Multilevel Model

DiscussionDiscussionResearch Implicationso We can reliably access the stress people bring to

clinical situations and its effect on current functioning

o We have developed a strong hypothesis in the relationship between stress, attributional style & depression

o We can incorporate specific stressor characteristicso We have demonstrated the value of multilevel

analysis

Clinical Implicationso Improvement in stress drives improvement in

depressiono But the effect of a depressive attributional style is

powerfulo Demonstrates value of addressing attributional

style early in therapy

Selected ReferencesSelected ReferencesAbramson, L. Y., Metalsky, G. I., & Alloy, L. B. (1989). Hopelessness depression: A theory-based subtype of depression. Psychological Review, 96, 358-372.

Abramson, L. Y., Seligman, M. E. P., & Teasdale, J. D. (1978). Learned Helplessness in Humans: Critique and Reformulation. Journal of Abnormal Psychology, 87(1), 49-74.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.

Beck, J. (1995). Cognitive Therapy: Basics and Beyond. New York: Guilford Press.

Beck, A. T., Rush, A., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press.

Cohen, S., Kessler, R. C., & Underwood Gordon, L. (1997). Measuring Stress: A Guide for Health and Social Scientists. New York, USA: Oxford University Press.

Selected ReferencesSelected ReferencesHammen, C. (2005). Stress and Depression. Annual Review of Clinical Psychology, 1, 293-319.

Hedeker, R., & Gibbons, R. D. (2006). Longitudinal Data Analysis. New Jersey, USA: John Wiley & Sons, Inc.

Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of Event Scale: A Measure of Subjective Stress. Psychosomatic Medicine, 41(3), 209-218.

Kaplan, H. B. (1996). Psychosocial Stress: Perspectives on Structure, Theory, Life-Course, and Methods. London: Academic Press, Inc.

Lambert, M. J. (2004). Bergin And Garfield’s Handbook of Psychotherapy and Behavior Change. New York, USA: John Wiley & Sons, Inc.

Singer, J., & Willett, J.B. (2003). Applied Longitudinal Analysis: Modeling Change and Event Occurrence. New York: Oxford University Press.

20090312 Doctoral Confirmation Presentation.ppt

Thank you!Thank you!

Contact:

Kimberly GoodDClinPsych candidateMassey University (Auckland, New Zealand)Email: ksgood@gmail.com