A central component of the metacognitive model of depression is the construct of metacognitive awareness, which is broadly defi ned as the ability to experience negative thoughts/feelings as mental events instead of being synonymous with one’s self (Teasdale
& Barnard, 1993; Teasdale, Segal, & Williams, 1995). Th is broadened perspective on negative events is encoded in memory and consequently represents a more adaptive way to relate to negative thoughts when they arise. Individuals high in metacognitive aware- ness, compared to individuals low in metacognitive awareness, are better able to evade depression and its sequelae when disidentifying with negative thoughts and feelings that arise in the face of a stressful situation. In recent years, several correlates of metacogni- tive awareness have received attention in correlational, prospective, experimental, and treatment studies.
Teasdale and colleagues (2002) examined the relationship of reduced metacognitive awareness to depression vulnerability and the eff ects of cognitive therapy on metacogni- tive awareness in relation to depression relapse. Th e fi rst study revealed that euthymic patients with a history of depression demonstrated signifi cantly lower levels of meta- cognitive awareness compared with age- and gender-matched nondepressed controls. In the second study, Teasdale et al. (2002) demonstrated that lower levels of metacognitive
awareness accessed fi ve months before baseline assessment predicted earlier relapse in patients with major depression. Th is fi nding is consistent with the hypothesis that the ability to relate to depressive thoughts and feelings within a wider perspective reduces the likelihood of future relapse. Th ese researchers also found that cognitive therapy increased accessibility to metacognitive sets with respect to negative thoughts and feel- ings compared with the comparison treatment. Diff erences between cognitive therapy and the comparison treatment were evidenced only on memories encoded during the treatment phase and not on prior memories, suggesting that changes in metacognitive awareness, as a result of cognitive therapy, refl ected cognitive therapy’s eff ects on the encoding of depressing experiences rather than artifactual eff ects of cognitive therapy on the way depressing experiences were described in recall. Th us, cognitive therapy is successful at increasing metacognitive awareness, and these metacognitive gains are as- sociated with positive outcomes.
Decentering
Another construct closely related to metacognitive awareness is decentering, which represents one’s ability to observe thoughts and feelings as temporary, objective events in the mind, as opposed to refl ections of the self that are necessarily true. From a decentered perspective, “. . . the reality of the moment is not absolute, immutable, or unalterable” (Safran & Segal, 1990, p. 117). For example, an individual engaged in decentering would say, “I am thinking that I feel depressed right now” instead of “I am depressed.” Decentering is present-focused and involves taking a nonjudgmental and accepting stance regarding thoughts and feelings. Although the concept of decen- tering can be found in traditional cognitive therapy (e.g., Beck et al., 1979), Teasdale and colleagues (2002, p. 276) suggest that it was primarily seen as “a means to the end of changing thought content rather than, as . . . the primary mechanism of thera- peutic change.” In other words, both Beck and Teasdale agree that cognitive therapy has always included decentering as a concept and a capacity that successfully treated depressed patients cultivate. However, a primary diff erence between cognitive therapy of depression as delivered by Beck and colleagues (1979) and Teasdale and colleagues (2002) is that for Beck, decentering is a capacity that allows an individual to make the important change in one’s core beliefs, whereas for Teasdale, decentering is, in and of itself, the capacity that produces durable relief from depression.
In a recent study, Fresco, Moore, and colleagues (2007) introduced the Experiences Questionnaire (EQ), an 11-item self-report measure of decentering. In a series of three studies, the factor structure was demonstrated in both student patient samples. Further, decentering, as assessed by the EQ, demonstrated theoretically meaningful correlates with concurrent self-report depression symptoms in college students (r = −.40), concurrent self-report (r =−.46) and clinician assessed (r =−.31) depression symptoms in depressed patients, experiential avoidance (r = −.49; Hayes et al., 2004), expressive suppression (r = −.31; Gross & John, 2003), and cognitive reappraisal (r = .25; Gross & John, 2003).
JWBT357c03_p57-82.indd 63
JWBT357c03_p57-82.indd 63 10/6/10 11:58:24 AM10/6/10 11:58:24 AM
Fresco, Segal, and colleagues (2007) examined the relationship between decentering and treatment response in a secondary analysis of Segal et al. (2006). Segal and col- leagues (2006) demonstrated that cognitive reactivity in conjunction with an emotion evocation challenge predicted relapse in patients treated to remission through either antidepressant medication (ADM) or cognitive behavioral therapy (CBT) in an 18- month prospective study. Fresco, Segal et al. (2007) demonstrated that patients who achieved a positive treatment response following random assignment to CBT evidenced signifi cantly greater gains in self-reported decentering compared to patients with a positive treatment response to ADM. Further, post-treatment levels of decentering in conjunction with low levels of cognitive reactivity were associated with the most durable treatment response. Th us, the ability to decenter is an important mechanism of change that can result from cognitive therapy for depression. However, Teasdale and colleagues (2002) posit that eff ective and durable treatment of MDD results from an increase in metacognitive capacities rather than the more traditional approach that cognitive- behavioral therapy has treatment eff ects by changing cognitive content.
Explanatory Style and Flexibility
Explanatory fl exibility in the assigning of causal explanations for negative events is a metacognitive extension of explanatory style, the cognitive diathesis at the heart of the reformulated learned helplessness theory of depression. Broadly construed, explanatory fl exibility is the ability to view events with a balance of historical and contextual infor- mation (Fresco, Rytwinski, & Craighead, 2007). Like explanatory style, explanatory fl exibility is assessed with the Attributional Style Questionnaire (ASQ; Peterson et al., 1982), a self-report measure in which respondents are presented with hypothetical nega- tive events and asked to record the main cause of the event, as well as numeric ratings on the causal dimensions of internality, stability, and globality. Whereas explanatory style is scored as the sum or average of the attributional dimensions, with higher scores indicating a more depressogenic style, explanatory fl exibility is computed as the intra- individual standard deviation on the ASQ dimensions of stability and globality for negative events. A small standard deviation is considered rigid responding, and a large standard deviation is interpreted as fl exible responding.
To date, studies in several contexts have demonstrated a relationship between ex- planatory fl exibility and depression. Fresco and colleagues have shown that explanatory style and explanatory fl exibility were relatively uncorrelated with one another, and that lower explanatory fl exibility scores were not simply proxies for extreme responding in terms of explanatory style (Moore & Fresco, 2007), that explanatory fl exibility is associ- ated with concurrent depression and anxiety symptoms (Fresco, Williams, & Nugent, 2006), and that levels of explanatory fl exibility at baseline were associated with higher levels of subsequent depression symptoms in the face of negative life events (Fresco, Rytwinski, & Craighead, 2007). In addition, a series of studies has demonstrated that an emotion provocation can engender reactivity in explanatory fl exibility for individuals
deemed at risk for reactivity (Fresco, Heimberg, Abramowitz, & Bertram, 2006), and that this reactivity interacts with intervening negative life events to predict depression symptoms eight weeks and six months later (Moore & Fresco, 2009). Further, reactiv- ity of explanatory fl exibility in the direction of reduced fl exibility was associated with reductions in parasympathetic tone during the mood priming challenge and inferior recovery of parasympathetic tone following the mood priming challenge (Fresco, Flynn, Clen, & Linardatos, 2009).
Two studies have examined the relationship of explanatory fl exibility to depression in the context of acute treatment for major depressive disorder. Specifi cally, in a second- ary analysis of the dismantling study of cognitive therapy of depression conducted by Jacobson and colleagues (1996), fi ndings revealed that depressed individuals responding to behavioral activation evidenced greater gains in explanatory fl exibility, whereas de- pressed patients who received a combination of behavioral activation plus disputation of negative automatic thoughts evidenced reductions in pessimistic explanatory style (i.e., less stable and global attributions for negative events) (Fresco, Schumm, & Dobson, 2009b). Furthermore, the combination of increased explanatory fl exibility and reduced pessimistic explanatory style predicted better protection from relapse during the two- year follow-up period (Fresco et al., 2009b). Th us, the behavioral activation part of the treatment may have resulted in changes in cognitive structure (i.e., fl exibility), whereas the disputation of negative thoughts may have infl uenced cognitive content change, both of which predicted better protection from relapse.
Fresco, Ciesla, Marcotte, and Jarrett (2009a) conducted secondary analysis of another recent randomized clinical trial examining the benefi ts of cognitive therapy of depres- sion. In the initial study, Jarrett and colleagues (2001) treated patients with MDD in an open-label fashion with cognitive therapy (CT) for 20 sessions. Responders were then randomly assigned to 10 additional CT sessions delivered over an eight-month period (Continuation Phase CT) or to an assessment-only condition. Patients were then fol- lowed with no further study treatment for 16 additional months. Findings revealed that patients who received continuation CT evidenced reduced rates of recurrence and relapse compared to patients who received no additional CT. In the secondary analysis conducted by Fresco and colleagues (2009a), fi ndings indicated that gains in explanatory fl exibility during the acute, open-label phase of CT preceded and predicted drops in self- report and clinician-assessed depression symptoms. However, continuation phase CT was not associated with additional gains in explanatory fl exibility. Similarly, explanatory fl exibility was not associated with rates of recurrence and relapse in the follow-up phase of the study. Th us, gains in explanatory fl exibility provided by behavioral approaches may result in reduced relapse and recurrence and hence more durable treatment eff ects.
Extreme Responding
Another metacognitive factor associated with depression symptoms is rigidity in assigning causal explanations to hypothetical negative or positive events on the ASQ. Specifi cally,
JWBT357c03_p57-82.indd 65
JWBT357c03_p57-82.indd 65 10/6/10 11:58:24 AM10/6/10 11:58:24 AM
several studies have found that extreme responses on the ASQ are related to poor clinical outcomes for patients with depression (Beevers, Keitner, Ryan, & Miller, 2003; Peterson et al., 2007; Teasdale, Scott, Moore, Hayhurst, Pope, & Paykel, 2001). In one study by Teasdale and colleagues (2001), 158 patients with residual depression currently being treated with antidepressant medication were randomly assigned to receive drug continuation with clinical management either alone or with cognitive therapy (CT). Participants were asked to report attributions on the ASQ before and following the treatment. Extreme responding (i.e., either “totally disagree” or “totally agree”), but not the content of responding (i.e., response to specifi c items) predicted relapse. Beevers and colleagues (2003) found similar results, in that poor change in extreme responding predicted a shorter amount of time until depressive symptoms returned in individuals treated for asymptomatic or partially remitted depression.
Support was also garnered for the relationship between extreme responding and depression by Petersen and colleagues (2007) who found that medication-only treatment for chronically depressed patients was associated with an increased frequency in extreme responding on the ASQ compared to no signifi cant change in responding when treated with CBT. Moreover, extreme responding on the ASQ predicted a signifi cantly higher likelihood of depressive re- mission in these patients. Th us, cognitive therapy seems to have an eff ect on by reducing the likelihood of extreme responding which in turn leads to less depressive symptoms.
Metacognition Summary
Numerous studies conducted by several independent investigators are converging on the role that metacognitive factors play in the treatment of major depressive disorder.
Two fi ndings are especially relevant at this point. First, to prevent relapse, it seems important to heighten the capacity to approach emotionally evocative situations with metacognitive awareness. Second, this metacognitive awareness is refl ected in several constructs that have demonstrated a relationship to depression: decentering, explanatory fl exiblity, and extreme responding. Specifi cally, existing psychosocial treatments can be augmented by targeting these capacities to achieve acute and durable treatment gains.
Many questions remain unanswered regarding metacognition and well-being. However, one important question that is being hotly pursued is whether metacognitive awareness can be cultivated more readily than with standard psychosocial treatments. Part of the answer to this question stems from the observation that these metacognitive skills bear a close resemblance to the capacities believed to arise from the practice of mental training exercises that derive from Buddhist and Hindu traditions. Th e conceptual similarities have led clinical scientists (e.g., Segal, Williams, & Teasdale, 2002) and aff ective neuro- scientists (e.g., Lutz, Slagter, Dunne, & Davidson, 2008) to take notice of these mental training exercises. Concentrative practices, such as mindfulness meditation, involve fo- cusing attention on a specifi c mental or sensory activity, such as repeated imagery, sensa- tions, sounds, or mantras. Cultivating such a practice is believed to foster metacognitive awareness (Teasdale et al., 2002). We now turn to a review of eff orts to infuse Buddhist mental training exercises into Western treatments for MDD.