Positive and Negative Affect in Cognitive Behavioral Therapy for Depression
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Positive and Negative Affect in Cognitive Behavioral Therapy for Depression Thesis Presented in Partial Fulfillment of the Requirements for the Degree Master of Arts. In The Graduate School of The Ohio State University By Megan L. Whelen, B.S. Graduate Program in Psychology The Ohio State University 2020 Thesis Committee: Dr. Daniel R. Strunk, Advisor Dr. Jennifer S. Cheavens Dr. Laura Wagner Copyright by Megan L. Whelen 2020 ABSTRACT Patients with major depressive disorder (MDD) tend to present with low positive affect (PA) and high negative affect (NA). Some have proposed that current psychotherapeutic approaches, such as cognitive behavioral therapy (CBT), treat NA while neglecting PA, and that targeting PA would provide additional improvement of depressive symptoms. However, few treatment studies have tracked NA and PA longitudinally to evaluate their role in CBT. In this study, I will test the relative importance of PA and NA for symptom improvement. In addition to affect, cognitive change is also thought to be important for symptom change in CBT, so I will also examine the relative importance of affect and cognitive change for symptom change. Further, cognitive change is thought to be an important driver, not only of symptom change during CBT, but also of affect change. That relationship may be reciprocal; mood reactivity studies suggest a predictive relationship between negative mood and distorted cognitions. The relation between affect and cognitive change has received little empirical attention. Accordingly, I will test the effects of cognitive change on PA and NA and the effects of PA and NA on cognitive change. Findings from this study will help to elucidate the role of positive and negative affect as well as cognitive change in CBT for depression. i Vita 2016……………………………………………………...B.S. Psychology, University of Houston 2018 to Present………......................................................Graduate Student, Department of Psychology, The Ohio State University Publications Fitzpatrick, O. M., Whelen, M. L., Falkenström, F., & Strunk, D. R. (2020). Who benefits the most from cognitive change in cognitive therapy of depression? A study of interpersonal factors. Journal of Consulting and Clinical Psychology, 88, 128-136. doi: 10.1037/ccp0000463 Robinson-Whelen, S., Taylor, H.B., Feltz, M., & Whelen, M. (2016). Loneliness among people with spinal cord injury: Exploring the psychometric properties of the 3item loneliness scale. Archives of Physical Medicine and Rehabilitation, 97, 1728-1734. doi: 10.1016/j.apmr.2016.04.008 Fields of Study Major Field: Psychology ii TABLE OF CONTENTS Abstract ................................................................................................................................ i Vita ...................................................................................................................................... ii List of Tables ..................................................................................................................... iv List of Figures ......................................................................................................................v 1. Introduction ......................................................................................................................1 1.1 Positive and Negative Affect ..................................................................................2 1.2 The Efficacy of CBT ...............................................................................................6 1.3 CBT Procedures ......................................................................................................7 1.4 Cognitive Change ....................................................................................................8 1.5 Potential Benefits of Negative Affect in Psychotherapy ......................................11 1.6 Cognitive Change and Affect ................................................................................14 1.7 Methodological Considerations .............................................................................16 1.7.1 Intervals Between Assessments ..............................................................16 1.7.2 Disaggregating Within and Between-Person Variance...........................18 1.7.3 Lagged Dependent Variables ..................................................................18 1.8 This Study ..............................................................................................................20 2. Methods..........................................................................................................................22 2.1 Participants .......................................................................................................22 2.2 Therapists .........................................................................................................23 2.3 Measures ..........................................................................................................23 2.3.1 Affect ......................................................................................................22 2.3.2 Depressive Symptoms .............................................................................23 2.3.3 Cognitive Change....................................................................................23 2.4 Analytic Strategy .............................................................................................24 3. Results ...........................................................................................................................28 4. Discussion .....................................................................................................................32 References .........................................................................................................................39 Appendix A: Tables and Figures .......................................................................................51 Figure 1 ..................................................................................................................51 Figure 2 ..................................................................................................................52 Figure 3 ..................................................................................................................53 Figure 4 ..................................................................................................................54 Figure 5 ..................................................................................................................55 Figure 6 ..................................................................................................................56 Figure 7 ..................................................................................................................57 Table 1 ...................................................................................................................58 Table 2 ...................................................................................................................59 Appendix B: Model Details ..............................................................................................60 iii List of Tables Table 1. Within-Person Correlations Among Variables ....................................................58 Table 2. Between-Person Correlations Among Variables .................................................59 iv List of Figures Figure 1. Representation of the RDSEM Model. ...............................................................51 Figure 2. Depressive Symptoms at each Session. ..............................................................52 Figure 3. Cognitive Change at each Session. .....................................................................53 Figure 4. Positive Affect at Pre- and Post-Session ............................................................54 Figure 5. Positive Affect Difference Scores from Pre- to Post-Session with CIs..............55 Figure 6. Negative Affect at Pre- and Post-Session ...........................................................56 Figure 7. Negative Affect Difference Scores from Pre- to Post-Session with CIs ............57 v Introduction Cognitive behavioral therapy (CBT) for depression is an efficacious treatment that utilizes cognitive and behaviorally-oriented change strategies. Cognitive change strategies are a central part of the treatment, and these strategies, as their name implies, are thought to elicit cognitive changes, which in turn improve patients’ moods (Beck, Rush, Shaw, & Emery, 1979; Lorenzo-Luaces, German, & DeRubeis, 2015). In general, it appears that cognitive change predicts symptom change, but its relation to affect change is unknown. Some have recently taken an interest in positive affect (PA)-focused treatments as a way to improve outcomes (e.g., Craske et al., 2019; Hofmann et al., 2015; Dunn, Widnall, et al., 2019). However, little is known about the effect current psychotherapeutic approaches have on PA relative to negative affect (NA), or whether efforts to target PA more directly would lead to additional symptom change. Other treatment developers have suggested that there are sometimes benefits to increasing a patient’s NA in-session (e.g., Hayes et al., 2007). Mood reactivity studies suggest that there is a relationship between affect and cognitive change. These studies use an artificial negative mood induction paradigm. When events in a patient’s life affect their mood,