University of Pennsylvania. From the SelectedWorks of Penn CCT

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1 University of Pennsylvania From the SelectedWorks of Penn CCT June 2, 2010 Is the Black Dog Really a Dalmatian? An investigation into whether Stress Impact and Attributional Style lead to different outcomes in DBT for Depression K. Good, Massey University P. Merrick, Massey University R. Fletcher, Massey University N. Kazantzis, La Trobe University Available at:

2 Is the Black Dog Really a Dalmatian? An investigation into whether Stress Impact and Attributional Style lead to different outcomes in CBT for Depression Paper presented at the World Congress of Behavioral and Cognitive Therapies in Boston, June 2-5, 2010 K. Good, Massey University, New Zealand P. Merrick, Massey University, New Zealand R. Fletcher, Massey University, New Zealand N. Kazantzis, La Trobe University, Australia

3 Overview o o o o Research topic Methodology Measures Defining variables Multilevel analysis Results Discussion

4 To get you thinking...

5 Research Gaps o o Depression and CBT What causes variation in client recovery? Stress-Diathesis Model Stress Impact Context Chronicity Financially-related Type of stress Depression Stress Load Capacity Diathesis Bio Psycho Social Attributional Style

6 Existing Research o 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 o o Methodological Limitations Mostly pre-post outcomes Few studies examining multiple predictors simultaneously

7 Treatment Study Context o o o Patients presenting with first-time depression 20 Sessions of CBT Rigorous therapist training and supervision Strict homework protocol and measures Patient measures Beck Depression Inventory (BDI-II) Every session Attributional Style Questionnaire (ASQ) Intake, sessions 5, 8, 20 and follow-ups Stress Impact? Definition? Objective vs Subjective measurement? Frequency of measurement?

8 Measuring 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

9 Measuring Stress Stage 2 Measuring Stress Across Time 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

10 Measuring Stress - Reliability Inter-Rater Reliability o Percentage Agreement: o 84% agreement across all training sessions o 100% agreement at the end of the training phase o Different sessions & therapists used in the training Item Analysis and Reliability of the Measure o Item Analysis Initial Items Final Items Included Intrusion Items Avoidance Items

11 How to analyse the data? Depression severity o 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

12 Fixed Effects Parameter Model A Model B Model C Model D Initial status, Intercept γ *** 24.92*** π 0i (1.82) (2.15) Rate of Change, Stress Curve γ Attributional Style γ π 1i Intercept γ *** - (0.10) Variance Components Stress Curve γ Attributional Style γ Level 1 Within-person σ 2 e 61.82*** 27.72***** (3.91) (1.80) Average patient had a significant change in depressive symptoms Level 2 In initial status σ *** *** (23.89) (33.25) Pseudo R 2 statistics and Goodness of Fit In rate of change σ * - (0.12) Covariance σ e * - (1.86) R 2 e - 55% R R Deviance 3, , AIC 3, , BIC 3, , Time explains 55% of within-patient variance

13 Fixed Effects Parameter Model A Model B Model C Model D Initial status, Intercept γ oo 18.73*** 24.92*** 26.29*** π 0i (1.82) (2.15) (4.30) Rate of Change, Stress Curve Leγ (3.24) Attributional Style Γ π 1i Intercept γ *** -.051** - (0.10) (0.18) Stress Curve γ * - - (0.14) Attributional Style γ Variance Components Level 1 Within-person σ 2 e 61.82*** 27.72***** 27.70*** (3.91) (1.80) (1.80) Level 2 In initial status σ *** *** *** (23.89) (33.25) (32.99) In rate of change σ * 0.16* - (0.12) (0.06) Covariance σ e * -2.63* - (1.86) (1.13) Pseudo R 2 statistics and Goodness of Fit R 2 e - 55% 55% R % R % Deviance 3, , , AIC 3, , , BIC 3, , , 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

14 Fixed Effects Parameter Model A Model B Model C Model D Initial status, Intercept γ oo 18.73*** 24.92*** 26.29*** 24.47*** Π 0i (1.82) (2.15) (4.30) (3.65) Rate of Change, Stress Curve γ (3.24) (3.87) Attributional Style γ ** (3.87) Π 1i Intercept γ *** -.051** -0.45* - (0.10) (0.18) (0.17) Stress Curve γ * (0.14) (0.14) Attributional Style γ (0.18) Variance Components Level 1 Within-person σ 2 e 61.82*** 27.72***** 27.70*** 27.70*** (3.91) (1.80) (1.80) (1.80) Level 2 In initial status σ *** *** *** 80.23*** (23.89) (33.25) (32.99) (23.25) In rate of change σ * 0.16* (0.12) (0.06) (0.05) Covariance σ e * -2.63* (1.86) (1.13) (0.85) Pseudo R 2 statistics and Goodness of Fit R 2 e - 55% 55% 55% R % 31% R % 55% Deviance 3, , , , AIC 3, , , , BIC 3, , , , 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

15 Attributional Style moderates the Stress-BDI relationship BDI-II Improvement Rapid Non-depressogenic Depressogenic Measured Minimal A depressognic attributional style slows the improvement in BDI-II caused by an improvement in stress Minimal Measured Rapid Stress Improvement

16 Preliminary Results Suggest Attributional Style (moderator) Stress Impact Depression (predictor) Stress & BDI-II correlate best when clients have nondepressogenic AS When they have mostly depressogenic AS, stress improvement is stunted it doesn t directly correspond to improved BDI-II scores

17 Post-Hoc Analyses Stressor Characteristics o Modal stressor: control, relationships, autonomy, finances, sequence o Impact on autonomy: therapy completion and attributional style o Impact on relationship: lower stress at conclusion o Impact on finances: therapy completion o Controllability: previous therapy o Chronicity: less severe intake BDI o Severity: gender and children Final model variables o Stress curve, attributional style, BDI intake severity, gender, therapy completion, marital status

18 Final Multilevel Model

19 Discussion Research Implications o 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 characteristics o We have demonstrated the value of multilevel analysis Clinical Implications o Improvement in stress drives improvement in depression o But the effect of a depressive attributional style is powerful o Demonstrates value of addressing attributional style early in therapy

20 Selected References Abramson, L. Y., Metalsky, G. I., & Alloy, L. B. (1989). Hopelessness depression: A theory-based subtype of depression. Psychological Review, 96, Abramson, L. Y., Seligman, M. E. P., & Teasdale, J. D. (1978). Learned Helplessness in Humans: Critique and Reformulation. Journal of Abnormal Psychology, 87(1), 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.

21 Selected References Hammen, C. (2005). Stress and Depression. Annual Review of Clinical Psychology, 1, 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), 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.

22 Thank you! Contact: Kimberly Good DClinPsych candidate Massey University (Auckland, New Zealand) Doctoral Confirmation Presentation.ppt

23 Appendices/ Additional Slides Doctoral Confirmation Presentation.ppt

24 Why Multilevel Analysis? o Nested data Sessions are nested within patients o Exploration of variation in individuals trajectories o Exploration of multiple predictors simultaneously BDI A- Style BDI BDI Stress A- Style Stress

25 Preliminary Multilevel Analysis - What s s interesting? Regression Analyses (Raw Data) Correlations (Initial Status and Rate of Change) BDI BDI ROC Stress Impact Stress Impact ROC Attributional Style Attributional Style ROC BDI BDI ROC neg Stress Impact Stress Impact ROC pos Attributional Style neg pos neg Attributional Style ROC neg

26 Possible Post-hoc Analyses... Results

27 Preliminary results show there is clear variability in the data... Intake BDI Scores 0 1 3, 5, 8, 9 2 1, 1, 3, 3, 4, 4, 5, 6, 8, 8 3 0, 2, 2, 3, 3, 7, 7 4 2, 3, 4, 6, 9 5 0, 3 Rate of Change in BDI 0 8, 9 1 0, 1, 3, 4, 6, 8, 9 2 1, 1, 2, 4, 6, 6 3 2, 4 4 2, 6 5 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

28 Building the Multilevel Model Model A BDI Model B BDI Time Model C BDI Time Stress Curve Model D BDI Time Stress Curve 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)? A-Style??

29 Preliminary Results BDI decreases over time

30 Preliminary Results Stress Impact decreases over time

31 Preliminary Results Attributional Style improves over time Negative Attributional Style and higher BDI intake Attributional Style: 0: Non depressogenic 1: Depressogenic Note. Average is calculated across all clients presenting for therapy at that particular session.

32 Measuring Stress - Reliability Inter-Rater Reliability o Percentage Agreement: Overall Intrusion Avoidance Total Thoughts 78% 50% 67% Emotions 83% 92% 89% Behaviour 100% 100% Physiology 100% 100% Total 86% 83% 84% Client 63 Intrusion Avoidance Total Thoughts 100% 100% 100% Emotions 100% 100% 100% Behaviour 100% 100% Physiology 100% 100% Total 100% 100% 100% o 84% agreement obtained across all training sessions o 100% agreement at the conclusion of the training phase o Different sessions and therapists were used in training

33 Reliability of Stress Measure Intrusion Items Avoidance Items Final Items Included

34 Stress Impact Rating Sheet NOT RATED 0 (NOT AT ALL) Language/ Description (e.g. words used) Stated not a problem OR is actively trying to change it Doesn t say it Implies it Doesn t say it Implies it Similar words Similar words Exact words Affect NONE LOW HIGH LOW HIGH HIGH INTRUSION ITEMS AVOIDANCE ITEMS Thoughts Thought about the stress when I didn t mean too N/R Pictures/Images of the stress popped into mind N/R Other things made me think about the stress N/R Emotion I had waves of strong feelings about the stress N/R Any reminder brought back feelings N/R Behaviour Physiology Trouble falling/staying asleep N/R Dreams about the stress N/R Tried to remove the stress from memory N/R I tried not to think about the stress N/R My feelings about the stress were numb N/R I had lots of feelings didn t want to deal with them N/R I felt as if it hadn t happened or wasn t real N/R Avoided letting myself get upset N/R Stayed away from reminders N/R Tried not to talk about it N/R COMMENTS ABOUT SESSION/STRESSOR: