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Clinical Psychology: An Information Processing Approach
Clinical Psychology: An Information Processing Approach P Fisher, University of Liverpool, Liverpool, UK ã 2012 Elsevier Inc. All rights reserved.
Glossary Attentional bias Differential allocation of attention to self-relevant threatening stimuli relative to neutral stimuli. Automatic processing Although no absolute consensus exists on the meaning of automatic processing, it generally refers to a cognitive process that operates unintentionally, without conscious awareness, is effortless, and requires no resources.
Introduction Over a century ago, Lightner Witmer established the first psychological clinic and formally proposed and outlined a structure of clinical psychology. Subsequently, clinical psychology has blossomed as a discipline and undergone many paradigmatic transitions; but all have deigned to improve our understanding of human behavior and to improve the efficacy of psychological interventions. The information processing (IP) approach has become one of preeminent frameworks in clinical psychology, particularly in the United Kingdom and the United States, in the twenty-first century. The IP approach has been extensively utilized in an attempt to account for the core features of a broad range of clinical disorders in all subdivisions of clinical psychology. More importantly, IP models have moved beyond descriptive phenomenology and are illustrating how particular types of attentional, interpretative, and memory biases are involved in the etiology and maintenance of psychological disorders, ranging from anxiety disorders in children and adults to IP models of autism. This development has raised the usefulness of the IP approach to a new level, namely that theoretical expositions are translated into psychological interventions, either in an additive fashion to existing treatments or as innovative and novel approaches. This article begins with a brief overview of the nature and development of the IP paradigm within cognitive psychology. It should be noted that within the rubric of cognitive psychology, IP can be considered from many perspectives, which accounts for the continued enthusiastic exploration of the IP approach from both theoretical and practical positions. IP can be studied from multiple perspectives including neurobiological and neuropsychological perspective. For example, understanding how lesions in specific brain regions map onto difficulties in learning or how specific neuropsychological deficits are associated with theory of mind difficulties in autism highlights the wide applicability of the approach. In this article, we will focus on how IP approach applies to emotional disorders. Following the overview of the IP paradigm, the value of the IP paradigm to clinical psychology is then presented, coupled with a discussion of the factors leading to the paradigmatic shift from behaviorism to cognitivism. The next section
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Cognitive architecture The organization of mental subsystems involved in the performance of information processing tasks. Metacognition Cognition about cognition; any knowledge or cognitive process that is involved in guiding, monitoring, controlling, or appraising cognition. Strategic processing In contrast to automatic processing, strategic or controlled processing is a conscious, effortful, volitional process which requires cognitive resources.
discusses some of the experimental methods, research findings, and clinical developments within the IP paradigm using attentional biases in anxiety as the main exemplar. The final section of this article focuses on two innovative clinical developments for anxiety disorders: cognitive bias modification procedures and metacognitive therapy. Both are grounded within the IP framework, but theoretically are very distinct.
Overview of the Information Processing Paradigm Empirical investigation within cognitive psychology includes, but is not limited to, the study of memory, attention, language, perception, higher level thought, reasoning consciousness, and cognitive development. The IP approach was developed as a framework within cognitive psychology to explain human behavior by reference to a cognitive system that mediates between incoming stimuli and behavior. The most familiar metaphor to explain the IP approach is the individual as a computer, and indeed the development of the IP approach is partially attributable to developments in computer technology during and following World War II. Specific guiding principles of the IP approach in cognitive psychology were outlined in the late 1970s. The first assumption was that people are autonomous individuals who intentionally engage with the other people and the environment. Next was the idea that the cognitive processor is a general-purpose, symbol-processing system involving both process, such as the allocation of attention, and content, such as an image in memory. Of central importance to the IP paradigm is the assumption that the cognitive system has a limited capacity. This proposition is crucial as it means there will be competition for resources leading to selective attention. For example, every day we are bombarded with stimuli and only a finite proportion can be selected and processed; how does this occur? Selective attention has engaged cognitive psychologists for over three decades and debate has centered on the extent to which selective attention is an automatic or strategic process. Although, a general agreement now exists that attentional bias is a combination of automatic and controlled processing, considerable theoretical disagreement continues as to the relative importance of each component in
Clinical Psychology: An Information Processing Approach
psychopathology. More importantly, the adopted theoretical positions on automaticity have had a profound influence on research directions and clinical practice. This issue will be discussed in more detail later. A further fundamental assumption of the IP paradigm is that IP takes time and that the time taken for a particular IP task can be specified. This allows predictions and testable hypotheses to be derived. For, example, attentional bias is inferred from differential response times to competing stimuli in a range of experimental tasks. The IP paradigm also specifies that cognitive processes are dependent upon, and constrained by, neuroanatomy and neurochemistry. Exploration of the interface between neuroscience and IP is an emerging field, which is providing valuable insights for the practice of clinical psychology. For example, neuroimaging assessment before and after psychological interventions is generating important data on the neurobiological mediators of change.
Evolution of the IP Paradigm Within Clinical Psychology Clinical psychologists working in adult mental health embraced the IP paradigm during the 1970s for two main reasons. First, there was growing dissatisfaction with the prevailing clinical paradigm of behaviorism. Although behavioral therapy was, and continues to be, an effective treatment for many clinical problems, the underpinning theory had insufficient explanatory power. Classical and operant conditioning processes were unable to explain fundamental aspects of specific disorders or the psychological mechanisms effecting clinical change. Interestingly, contemporary theories of the mechanisms of change in behavior therapy explicitly focus on cognitive constructs and processes, rather than on the two-factor model that had dominated theorizing from the 1950s to the 1970s. The second key influence was the development of schema theory proposed by Aaron Beck. This clinical theory placed schemas at the heart of emotional disorders. The construct of schemas was appropriated from work conducted on early research on memory processes. Schemas were defined as relatively stable and enduring cognitive structures that influence how an individual perceives and interprets information. The content of the schemata is thought to be of paramount importance and differentiates between anxiety and depressive disorders. Specifically, depression or anxiety will occur when a matching life event activates congruent knowledge stored in the long-term memory. Typically, depressogenic schemas incorporate negative beliefs about the world, the future, and themselves as being inadequate or worthless. In anxiety disorders, the content of schemas concerns personal vulnerability, uncertainty, and danger. It is hypothesized that schema activation results in biased IP, most readily seen by an increased presence of negative automatic thoughts and interpretative biases, more commonly referred to as cognitive distortions. Examples of cognitive distortions include selectively attending to one component of an event and ignoring other relevant aspects, or thinking in all or nothing terms. The original exposition of schema theory was not explicitly developed within the IP paradigm; the theory clearly implicates many cognitive processes including memory, attention, and perception. Furthermore, the theory states that schemas
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guide processing of incoming stimuli and influence perception and understanding, which in turn is translated in how people behave. However, neither the original exposition nor subsequent IP accounts of schema theory have provided a cogent model of how schemas guide IP and result in persistent emotional distress. It remains to be explained why a declarative belief such as ‘the world is a threatening place’ should result in heightened levels of anxiety and persistent worry. Schema theory remains a hugely influential and useful clinical theory, but has a number of conceptual limitations when considered from an explicit IP perspective. Notwithstanding this issue, the undoubted success of cognitive therapy continues to stimulate considerable research interest in the cognitive processes involved in the etiology and maintenance of clinical disorders. Cognitive behavior therapy (CBT) has become the predominant psychological treatment approach of the twenty-first century, having been extensively evaluated in over 400 randomized controlled trials and the breadth of application continues to grow. It is widely recognized that improvement in the efficacy of CBT approaches for specific disorders, such as social phobia, is a direct result of integrating schema and IP theories. Therefore, the IP paradigm will continue to flourish as it is assumed that further unraveling of cognitive processes, such as attentional biases in anxiety disorders, will enable increasingly effective interventions to be developed.
Significance of the IP Paradigm to Clinical Psychology The value of any paradigm resides in its ability to generate theories and well-specified models; the IP paradigm has excelled in this regard. There are a multitude of theories and associated models derived from the core assumptions of the IP paradigm across all subspecialities of clinical psychology. Within adult mental health, a multitude of generic and disorder-specific models exist, some drawing very specifically on the IP paradigm and others integrating components drawn from the IP paradigm with other schools of thought. Once models have been developed and empirically evaluated, the next step is to translate the models into effective psychological interventions and again work conducted under the IP paradigm has been extremely successful and has produced many highly differentiated treatments. Both of these core strengths of the IP paradigm can be illustrated with reference to posttraumatic stress disorder (PTSD). The central premise of many models of PTSD is that memory processes operate differently to normal memories as a consequence of the traumatic conditions in which the memories were encoded. For example, the dual representation theory proposes that different components of trauma memories are stored in different memory systems. Specifically, features of the traumatic experiences that are attended to consciously are stored in the verbally accessible memory (VAM) system and can be recalled easily. The nature of the beliefs in this system is hypothesized to be dysfunctional and represents common beliefs expressed by trauma patients, such as ‘I am to blame, it was my fault.’ In contrast, there are other aspects of the traumatic experience which were not consciously attended to, but were encoded in a situationally accessible memory (SAM). These memories are only recalled when triggered by a trauma cue and result in increased
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physiological reactivity, and reexperiencing symptoms. The model proposes that psychological treatment must correct information stored in both memory systems; therefore, cognitive restructuring methods are used to correct maladaptive beliefs, whereas exposure strategies are required to modify the physiological components of PTSD. In contrast to the models of PTSD, which specify a critical role for memory disorganization, the metacognitive model of PTSD proposes that metacognitive beliefs and processes are more important in maintaining PTSD than specific aspects of memory such as encoding and retrieval. Indeed, the metacognitive model argues that maintaining factors in PTSD relates to a particular processing style called the cognitive attentional syndrome (CAS). The CAS consists of high levels of perseverative thinking, threat monitoring, and coping behaviors that are guided by metacognitive beliefs and proceduralized knowledge that become active following the trauma experience and subsequent symptoms. Patients engage in high levels of worry because they hold positive metacognitive beliefs about the usefulness of worry as a coping strategy and also because they have negative metacognitive beliefs about the uncontrollable nature of worry. In relation to memory, an example of positive metacognitive belief would be ‘I must be remember all aspects of the trauma in order to move on,’ whereas negative metacognitive beliefs focus on the dangers and consequences of not being able to recall every aspect of the event. These two categories of metacognitive belief combine to keep the person focused on the threat and engage in continued processing of the trauma experience. Treatment would focus on the modification of positive and negative metacognitive beliefs about the CAS and would not involve cognitive restructuring of beliefs in the cognitive domain or use exposure exercises. These two examples illustrate the development and diversity of disorder-specific models that have been developed under the broad framework of the IP paradigm. Moreover, the two models highlight that the resultant treatments are distinct in how individuals with PTSD are assessed, conceptualized, and treated. The development of models within an IP framework has directly influenced diagnostic classificatory systems such as the International Classification of Disease (ICD) and Diagnostic and Statistical Manual (DSM). Since generalized anxiety disorder (GAD) entered the diagnostic taxonomy in 1980, it has undergone substantive changes. Originally, GAD was conceptualized primarily as a disorder of anxiety but with very limited reference to cognitive processes. In the latest incarnation of the Diagnostic and Statistical Manual (DSM-IV), the cardinal diagnostic feature of GAD is a cognitive process, namely excessive worry, which a person finds difficult to control. Such diagnostic changes are very significant as they provide both an impetus and direction for research. In the case of GAD, research is ever more focused on understanding the psychological processes which underpin worry. Panic disorder represents another clear illustration of how diagnoses for anxiety disorders have been shaped by research conducted under the IP rubric. Panic disorder is defined according to the psychological mechanisms responsible for the maintenance of the disorder. Patients with panic disorder catastrophically misinterpret symptoms of anxiety which is both the primary target for intervention and the cardinal feature of the disorder.
Evidently, clinical psychology has benefited from research conducted within the IP paradigm in many ways. In addition to the taxonomic, treatment, and model development, the IP framework continues to broaden its horizons as it is being applied to an increasing number of clinical problems. Furthermore, the IP approach is contributing to our understanding of vulnerability to relapse following treatment or indeed the genesis of clinical disorders as can be seen in the child psychopathology literature where research is providing illuminating data on potential pathways to emotional difficulties. Finally, evidence is steadily being accumulated that models and treatments located within an IP paradigm are producing increasingly more effective and time-efficient psychological treatments.
Emotional Disorders and Information Processing Biases A wealth of studies using a range of experimental tasks have demonstrated that people with elevated levels of anxiety demonstrate an attentional bias toward threatening stimuli compared to neutral stimuli. Such results are in accord with clinical accounts in which patients describe focusing their attention on signs of threats, for example internal sources such as unwanted thoughts and feelings or external signs of possible threat, typified by hypervigilence for signs of danger in PTSD patients. However, there may be both qualitative and quantitative difference in attentional allocation in the natural environment compared to laboratory experiments; this conundrum remains to be resolved. Nevertheless, research into biased IP in emotional disorders has made substantial advances over the past two decades. Early work in this area took a rather dichotomized approach to explain the IP biases observed in emotional disorders. For example, the majority of research found that anxiety disorders were characterized by selective attention toward threatening stimuli whereas affective disorders did not show this bias. Alternatively, depression and not anxiety was characterized by explicit memory biases toward self-relevant negative information. However, as the experimental paradigms and theorizing increased in sophistication, it has become evident that both anxiety and depression are characterized by a range of IP biases. Recent studies on depressed adolescents and on adults experiencing suicidal ideation have shown preferential attentional bias for self-relevant stimuli. A general finding is that the degree to which threatening stimuli are perceived as self-relevant is correlated with the magnitude of attentional bias. In PTSD, the interference effect observed on the emotional Stroop task is greater when the stimuli are most self-relevant; so, in combat veterans with PTSD, the interference effect will be greater for military stimuli than general trauma stimuli. A similar picture is seen in obsessive compulsive disorder, whereby biases are only observed when the stimuli are relevant to the individual specific obsessional concerns.
Components of Attentional Bias Attentional bias in anxiety comprise at least three components, which change according to the stage of IP. The first stage is facilitated attention, in which threatening stimuli are detected
Clinical Psychology: An Information Processing Approach
more rapidly than neutral or less threatening stimuli. The next stage is difficultly in disengaging from threat; in other words, anxious people find it difficult to shift their attention away from threatening stimuli; and the final stage is attentional avoidance, where people allocate their attention away from threatening stimuli. A broad range of experimental tasks (described below) have repeatedly demonstrated attentional bias at each stage of processing; however, the mediating mechanism(s) underpinning each component remains a source of controversy. Understanding the mechanisms responsible for attentional bias would facilitate the development of theoretically cogent and defined interventions.
Experimental Paradigms The emotional Stroop was the first task used extensively to measure attentional bias in anxiety. In this task, participants are presented with a series of threatening and neutral words printed in different colors and the objective is to name the color that each word is printed in as quickly as possible whilst ignoring the semantic content of the word. Response times are measured and differences in latencies of color-naming between threat words and neutral words are indicative of attentional bias. Across a range of anxiety disorders, studies using the emotional Stroop have found increased latencies of color-naming of threat words. The most frequent conclusion is that slower color naming is attributable to an automatic processing bias in anxiety which directs attention toward threatening material. However, the emotional Stroop has been the center of considerable debate for many years as numerous authors have argued that the mediating mechanism underpinning is not rapid orientation or engagement with threatening stimuli but instead primarily reflects a later stage of processing, namely difficulty engaging with threatening material. Researchers have also suggested that attempts by participants to suspend further processing of the threat cues slow colornaming. Other explanations for the interference effect on the emotional Stroop relate to the other cognitive and emotional processes involved in undertaking the task as it is not a pure measure of attention. It may be that participants process neutral and emotional stimuli to the same extent; however, the negative stimuli produce an increase in emotion which inhibits reaction time performance. This brief account of the emotional Stroop highlights that interpretation of the observed interference effect is highly problematic. Overall, evidence suggests that the interference effect is not attributable to just one component of attentional bias, and that the component which explains most of the effect appears to be difficultly disengaging from threat, rather than facilitated attention. An alternative task that has also been widely employed in assessing attentional bias toward threat and overcomes some of the limitations of the emotional Stoop is the dot probe task. This task is also thought to have greater ecological validity as it does not rely on words as stimuli and tends to use pictures that have personal meaning for the particular problem being investigated. For example, if a spider phobic was completing this task, then the neutral stimuli might be a range of everyday objects or animals that do not provoke distress, whereas the threatening picture would be relevant to the phobia. In this task, two pictures are presented simultaneously on a computer
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screen. The pictures then disappear and a probe replaces one of the pictures. Participants are asked to indicate as rapidly as possible (by a button press) which stimulus has been replaced by the probe. Attentional bias is inferred through faster responses to the probes that replace threatening stimuli relative to the neutral stimuli. A major advantage of the dot probe task is that the interval between stimulus presentation and the probe can be varied, enabling assessment of the time course of the attentional bias. Studies which have examined the effects of facilitated attention and difficulties in disengagement overwhelmingly find that the attentional bias effect is accounted for by delayed disengagement. This does not mean that a fast automatic orienting bias does not occur, but it does imply that the rapid orienting response is not contributing as significantly to the maintenance of anxiety disorders as early research indicated. Two other experimental tasks are frequently used to measure attentional biases. The visual search task allows assessment of spatial allocation of attention and speed of responding. Participants are asked to search for the target word amongst distractor words (as in a word search puzzle). A single threat word might be embedded in a matrix of neutral words and the reverse condition would ask participants to search for the neutral word amongst a set of self-relevant emotional words. Attentional bias is inferred from faster detection of threat words embedded in neutral words relative to detecting a neutral word embedded amongst other neutral words. The alternative condition is where participants are slower to detect neutral words in a matrix of threat words compared to detection of a neutral target word in a matrix of neutral stimuli. The final task that has been used frequently in attentional bias research is the spatial cueing task. In this task, the participant is asked to rapidly identify a target stimuli but they are cued (either by a neutral or threatening cue) to a spatial location on the computer screen before the target appears. The cue may be valid, in that the target appears in the same spatial location as the cue; alternatively, it may be invalid, in which case the target stimulus appears in a different spatial location to the cue. Attentional bias is inferred by faster response times for threatening cues in the correct spatial location or by slower response times on invalid trials. Both the visual search task and the spatial cueing task have produced robust results demonstrating attentional bias for threatening stimuli in a range of anxiety disorders, accounted for by difficulties in disengaging from threat. As experimental tasks have increased in sophistication and ability to measure the different components of attentional bias, the most robust finding is that people with elevated levels of anxiety have difficulty in disengaging from threatening stimuli. In other words, anxiety disorders are characterized by a lack of flexibility of allocation of attention. In the next section, the issue of whether attention is primarily an automatic or controlled process is discussed in more detail.
Automatic and Controlled Processing One of the most enduring theoretical disputes within IP accounts of emotional disorders and particularly in relation to attentional biases in anxiety is whether the observed bias is attributable to automatic or controlled processing. Automatic
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processing has been defined as uncontrollable, unintentional, unconscious, capacity free, and effortless, whereas controlled or strategic processing is an intentional, volitional process, which requires conscious awareness, effort and is constrained by capacity limitations. As IP accounts of anxiety were proposed during the course of the 1980s and 1990s, the distinction between controlled and automatic processing became highly significant because it determined how psychological treatments for anxiety were developed. If attentional and interpretative biases are automatic processes, then this implies that psychological therapies should focus on enabling patients to cope and manage with anxiety or possibly through extended retraining, attentional biases could be alleviated. The alternative view that attentional bias is primarily a product of controlled processing will result in a very different psychological intervention, as the focus would be on modifying processing configurations, guided by beliefs/knowledge which is stored in long-term memory structures. Examination of the automaticity of attentional biases in anxiety has moved away from a simple all-or-nothing dichotomy to exploring whether the different stages of processing are related primarily to automatic or controlled processing. The predominant view was, and continues to be, that facilitated attention represents an automatic process whereas the later stages of attentional bias (delayed disengagement and avoidance of threat) come increasingly under strategic control. However, research thus far has not unequivocally demonstrated that any stage of processing is either completely strategic or completely automatic. This is despite many studies concluding that attentional bias is an automatic process but this conclusion is unwarranted as these studies have generalized from an experimental task that has only manipulated one component of automaticity. For example, studies using the emotional Stroop have tried to determine whether the interference effect is attributable to an automatic process by using masked presentations. This task involves very brief presentation of the stimuli (<20 ms) and then the stimulus is masked for up to 480 ms before the next stimulus is presented. The idea behind this is that such rapid presentation prevents conscious awareness and therefore the observed interference effect reflects an automatic process. However, only degree of awareness has been manipulated and there is a question mark over the extent to which subliminal presentations with backward masking actually preclude conscious awareness. Therefore at best, studies have demonstrated that attentional biases are partially automatic, as no studies have successfully manipulated all facets of automaticity. This raises an important question, which is whether research focusing on differentiating automatic from controlled processing is meaningful or clinically useful as the majority of cognitive processes appear to be a combination of automatic and controlled processing. The more clinically useful question is determining whether strategic processing can exert an influence over the more automatic components of attentional bias. Theories differ in the importance placed on each stage of processing. Some theories emphasize that anxious people exhibit an enhanced automatic bias for threat during the early stages of processing and avoidance of threat in the later stages of processing, often labeled as the vigilance–avoidance model. Others have argued that the early stages of processing
and the automatic or rapid orienting response have little impact on anxiety, instead arguing that anxiety is maintained by a difficulty in disengaging from threat. As reviewed earlier in the article, the evidence from various analyses of experimental tasks would indicate that early components of attention are less important than later stage of processing in the maintenance of anxiety disorders.
Clinical Applicability of Information Processing Models and Treatments The ultimate test of the value of the IP approach is whether it has resulted in improved treatment efficacy as a result of translating theoretical advances into clinical treatments. The answer to this question depends on the treatment and disorder being investigated. Cognitive therapy for depression remains virtually unchanged in terms of treatment delivery and treatment efficacy over the past 30 years. Findings from empirical work on memory biases and attentional processes in depression have not been incorporated into cognitive therapy. The opposite is true for psychological treatments of anxiety disorders, where there are clear developments in the focus and nature of interventions for almost all anxiety disorders.
Cognitive Bias Modification Following on from research demonstrating that individuals with anxiety disorders show a preferential attention for threatening stimuli, it was argued that attentional bias was an integral component of anxiety disorders. Prospective studies found that facilitated attention bias was predictive of greater emotional reactivity to a stressful event. Furthermore, that when nonanxious people were trained to either direct their attention toward or away from threat, those individuals who were trained to orient toward threat showed significantly higher emotional responses to a stressor task. As a result of such studies, it was hypothesized that people suffering from an anxiety disorder could be trained to reduce their attentional bias toward threat. Therefore, cognitive bias modification (CBM) procedures, designed to decrease attentional bias in anxiety disorders, have been developed. It has been argued that CBM procedures may have an important role in the treatment of anxiety disorders, especially as the current level of efficacy of psychological treatments for many anxiety disorders is somewhat limited. CBM procedures typically involve a modification of the dot probe task and train people to orient rapidly away from threatening stimuli. Recent applications of CBM procedures in clinical samples have shown promising results including significant reductions in anxiety and depression in a GAD sample, after a 4-week training program. However, a number of issues require resolution. First, these procedures are predicated on the assumption that the early stage of attentional bias, facilitated attention toward threat, is being modified. However, it appears that the CBM procedures are operating at the later stages of attentive processing of threat, namely avoidance of threat. In other words, CBM techniques are modifying strategic rather than automatic processing. A related issue is that if people are being trained to look away from threat, then this has important clinical
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implications. Patients use avoidance to modulate anxiety, but with an important consequence, they do not learn more effective methods of responding to threat. A further issue with the CBM results is that although GAD patients showed reductions in overall levels of anxiety and depression, the cardinal feature of GAD, namely worry, remained comparatively unchanged. Studies such as these highlight that modifying attentional processes may result in reductions of anxiety, but anxiety disorders are not only characterized by attentional biases and other important aspects of the disorder remain unchanged. Further research is required to delineate the mechanism of action, especially as it is possible that these training procedures are actually counterproductive in the long run. Despite the need to clarify these issues, the recent studies on CBM raise a number of fascinating possibilities including whether the strategies can be successfully incorporated in existing CBT protocols with a resultant increase in treatment efficacy.
The Self-Regulatory Model of Executive Dysfunction in Emotional Disorders One model that has been developed within an IP framework to explain the persistence of emotional disorders is the Self-Regulatory Executive Function model (S-REF). This model was proposed by Adrian Wells and Gerald Matthews as a transdiagnostic understanding of the factors involved in the maintenance of psychological disorder. The model attempted to overcome some of the limitations of schema theory and develop a model of psychopathology that was explicitly developed within the IP framework. The model specifies that psychological disorders should be conceptualized as predominantly top-down or conscious processes, with a set of self-regulatory strategies. According to the model, a particular style of thinking and coping with negative thoughts and feelings results in the exacerbation and maintenance of emotional distress. This particular style of thinking has been termed the CAS and consists of perseverative thinking, threat monitoring, and counterproductive coping strategies. In developing the model, the authors returned to earlier work on attention, which specified that there were different levels of control in the form of automatic and controlled processing. The S-REF model proposes that emotional distress is linked primarily to biases in the selection and execution of controlled processes for appraising and coping with intrusive cognitive and emotional events. More specifically, an individual’s strategy for thinking and self-regulation in response to unwanted thoughts and feelings can either intensify and maintain negative emotions or result in brief emotional reactions. Emotional disorders such as anxiety and depression occur when the style of thinking and coping inadvertently leads to persistence and strengthening of emotional responses. The CAS is guided by metacognitive beliefs concerning (a) the benefits of engaging in each aspect of the CAS, for example ‘worry helps me cope’ and (b) the uncontrollable nature of the CAS, for example ‘my worry is out of my control, I cannot stop myself from worrying.’ In MCT, the CAS and the supporting metacognitive beliefs are the psychological processes that are targeted in therapy.
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In contrast to cognitive therapy and CBM approaches, metacognitive theory does not link psychological problems to automatic processing biases or the content of schemas. Instead, metacognitive theory specifies that psychological problems are attributable to conscious and volitional strategies. In relation to the experimental paradigms used to assess attentional bias earlier in the article, metacognitive theory does not link the observed effects to activation of schemas or automatic processing but attributes them to strategy selection. In anxiety disorders, patients have a strategy of maintaining attention on sources of threat and engaging in worry-based processing as a means of coping. The S-REF model is based on three basic levels of cognition: a level of reflexive and automatic processes that run with minimal or no conscious involvement. These processes may generate intrusions into consciousness that capture attention. The next level is an online form of processing which is conscious and capacity-limited, responsible for regulating and implementing appraisal and action. The final level is stored knowledge in long-term memory. The immediate activities of the online processing require access to stored knowledge in order to run. Online processing is guided by knowledge or beliefs that are metacognitive in nature. In line with one of the core values of the IP approach, the S-REF theory has generated many disorder-specific models, including models of depression, GAD, PTSD, social phobia, and obsessive compulsive disorder. Current research is evaluating the applicability of the S-REF model in an even broader range of issues such as alcoholism, psychosis, and persistent distress in survivors of cancer and myocardial infarctions. Evaluation of treatment efficacy of metacognitive therapy is in the early stages, but it is producing very high recovery rates across a range of clinical disorders.
Conclusions IP models proliferate in clinical psychology, but the disparate nature of the underpinning theories leads to very different treatment approaches. This is a strength of the IP approach as it provides clinical psychology with a rich theoretical basis, from which further advancements can be achieved. The generation of novel interventions in the form of CBM strategies and metacognitive approaches are exciting innovations that hold considerable promise for the continually evolving practice of clinical psychology. In summary, the IP paradigm has resulted in a wealth of research and clinical developments that ultimately result in significant therapeutic benefits.
See also: Anxiety and Fear; Anxiety Disorders; Attention; Cognitive Behavior Therapy; Cognitive Bias.
Further Reading Amir N, Burns M, Beard C, and Bomyea J (2009) Attention modification program in individuals with generalized anxiety disorder. Journal of Abnormal Psychology 118(1): 28–33.
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Bar Haim Y, Lamy D, Pergamin L, Bakermans-Kranenberg M, and van Ijzendoorn M (2007) Threat-related attentional bias in anxious and nonanxious individuals: A meta-analytic study. Psychological Bulletin 133: 1–24. Beck AT (1976) Cognitive Therapy and the Emotional Disorders. New York: International Universities Press. Beck AT and Clark DA (1997) An information processing model of anxiety: Automatic and strategic processes. Behavior Research and Therapy 35: 49–58. Brewin CR, Dalgleish T, and Joseph S (1996) A dual representation theory of posttraumatic stress disorder. Psychological Review 103(4): 670–686. Cisler J and Koster E (2010) Mechanisms of attentional bias toward threat in anxiety disorders: An integrative review. Clinical Psychology Review 30: 203–216. Flavell JH (1979) Metacognition and metacognitive monitoring: A new area of cognitive-developmental inquiry. American Psychologist 34: 906–911. Hankin BL, Abela J, Gibb BE, and Flory K (2010) Selective attention to affective stimuli and clinical depression among youths: Role of anxiety and specificity of emotion. Journal of Abnormal Psychology 119: 491–501.
Ingram RE (1990) Self-focused attention in clinical disorders: Review and conceptual model. Psychological Bulletin 107: 156–176. Lachman R, Lachman JL, and Butterfield EC (1979) Cognitive Psychology and Information Processing: An Introduction. Hillsdale, NJ: Erlbaum. Mathews A and MacLeod C (2005) Cognitive vulnerability to emotional disorders. Annual Review of Clinical Psychology 1: 167–195. Phaf RH and Kan K (2007) The automaticity of emotional Stroop: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry 38: 184–199. Wells A (2000) Emotional Disorders and Metacognition: Innovative Cognitive Therapy. Chichester, UK: Wiley. Wells A and Matthews G (1996) Modeling cognition in emotional disorder: The S-REF Model. Behavior Research and Therapy 34(11): 881–888. Williams JMG, Watts FN, MacLeod C, and Mathews A (1988) Cognitive Psychology and Emotional Disorders. Chichester, UK: Wiley.
Glossary Attentional bias Differential allocation of attention to self-relevant threatening stimuli relative to neutral stimuli. Automatic processing Although no absolute consensus exists on the meaning of automatic processing, it generally refers to a cognitive process that operates unintentionally, without conscious awareness, is effortless, and requires no resources.
Introduction Over a century ago, Lightner Witmer established the first psychological clinic and formally proposed and outlined a structure of clinical psychology. Subsequently, clinical psychology has blossomed as a discipline and undergone many paradigmatic transitions; but all have deigned to improve our understanding of human behavior and to improve the efficacy of psychological interventions. The information processing (IP) approach has become one of preeminent frameworks in clinical psychology, particularly in the United Kingdom and the United States, in the twenty-first century. The IP approach has been extensively utilized in an attempt to account for the core features of a broad range of clinical disorders in all subdivisions of clinical psychology. More importantly, IP models have moved beyond descriptive phenomenology and are illustrating how particular types of attentional, interpretative, and memory biases are involved in the etiology and maintenance of psychological disorders, ranging from anxiety disorders in children and adults to IP models of autism. This development has raised the usefulness of the IP approach to a new level, namely that theoretical expositions are translated into psychological interventions, either in an additive fashion to existing treatments or as innovative and novel approaches. This article begins with a brief overview of the nature and development of the IP paradigm within cognitive psychology. It should be noted that within the rubric of cognitive psychology, IP can be considered from many perspectives, which accounts for the continued enthusiastic exploration of the IP approach from both theoretical and practical positions. IP can be studied from multiple perspectives including neurobiological and neuropsychological perspective. For example, understanding how lesions in specific brain regions map onto difficulties in learning or how specific neuropsychological deficits are associated with theory of mind difficulties in autism highlights the wide applicability of the approach. In this article, we will focus on how IP approach applies to emotional disorders. Following the overview of the IP paradigm, the value of the IP paradigm to clinical psychology is then presented, coupled with a discussion of the factors leading to the paradigmatic shift from behaviorism to cognitivism. The next section
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Cognitive architecture The organization of mental subsystems involved in the performance of information processing tasks. Metacognition Cognition about cognition; any knowledge or cognitive process that is involved in guiding, monitoring, controlling, or appraising cognition. Strategic processing In contrast to automatic processing, strategic or controlled processing is a conscious, effortful, volitional process which requires cognitive resources.
discusses some of the experimental methods, research findings, and clinical developments within the IP paradigm using attentional biases in anxiety as the main exemplar. The final section of this article focuses on two innovative clinical developments for anxiety disorders: cognitive bias modification procedures and metacognitive therapy. Both are grounded within the IP framework, but theoretically are very distinct.
Overview of the Information Processing Paradigm Empirical investigation within cognitive psychology includes, but is not limited to, the study of memory, attention, language, perception, higher level thought, reasoning consciousness, and cognitive development. The IP approach was developed as a framework within cognitive psychology to explain human behavior by reference to a cognitive system that mediates between incoming stimuli and behavior. The most familiar metaphor to explain the IP approach is the individual as a computer, and indeed the development of the IP approach is partially attributable to developments in computer technology during and following World War II. Specific guiding principles of the IP approach in cognitive psychology were outlined in the late 1970s. The first assumption was that people are autonomous individuals who intentionally engage with the other people and the environment. Next was the idea that the cognitive processor is a general-purpose, symbol-processing system involving both process, such as the allocation of attention, and content, such as an image in memory. Of central importance to the IP paradigm is the assumption that the cognitive system has a limited capacity. This proposition is crucial as it means there will be competition for resources leading to selective attention. For example, every day we are bombarded with stimuli and only a finite proportion can be selected and processed; how does this occur? Selective attention has engaged cognitive psychologists for over three decades and debate has centered on the extent to which selective attention is an automatic or strategic process. Although, a general agreement now exists that attentional bias is a combination of automatic and controlled processing, considerable theoretical disagreement continues as to the relative importance of each component in
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psychopathology. More importantly, the adopted theoretical positions on automaticity have had a profound influence on research directions and clinical practice. This issue will be discussed in more detail later. A further fundamental assumption of the IP paradigm is that IP takes time and that the time taken for a particular IP task can be specified. This allows predictions and testable hypotheses to be derived. For, example, attentional bias is inferred from differential response times to competing stimuli in a range of experimental tasks. The IP paradigm also specifies that cognitive processes are dependent upon, and constrained by, neuroanatomy and neurochemistry. Exploration of the interface between neuroscience and IP is an emerging field, which is providing valuable insights for the practice of clinical psychology. For example, neuroimaging assessment before and after psychological interventions is generating important data on the neurobiological mediators of change.
Evolution of the IP Paradigm Within Clinical Psychology Clinical psychologists working in adult mental health embraced the IP paradigm during the 1970s for two main reasons. First, there was growing dissatisfaction with the prevailing clinical paradigm of behaviorism. Although behavioral therapy was, and continues to be, an effective treatment for many clinical problems, the underpinning theory had insufficient explanatory power. Classical and operant conditioning processes were unable to explain fundamental aspects of specific disorders or the psychological mechanisms effecting clinical change. Interestingly, contemporary theories of the mechanisms of change in behavior therapy explicitly focus on cognitive constructs and processes, rather than on the two-factor model that had dominated theorizing from the 1950s to the 1970s. The second key influence was the development of schema theory proposed by Aaron Beck. This clinical theory placed schemas at the heart of emotional disorders. The construct of schemas was appropriated from work conducted on early research on memory processes. Schemas were defined as relatively stable and enduring cognitive structures that influence how an individual perceives and interprets information. The content of the schemata is thought to be of paramount importance and differentiates between anxiety and depressive disorders. Specifically, depression or anxiety will occur when a matching life event activates congruent knowledge stored in the long-term memory. Typically, depressogenic schemas incorporate negative beliefs about the world, the future, and themselves as being inadequate or worthless. In anxiety disorders, the content of schemas concerns personal vulnerability, uncertainty, and danger. It is hypothesized that schema activation results in biased IP, most readily seen by an increased presence of negative automatic thoughts and interpretative biases, more commonly referred to as cognitive distortions. Examples of cognitive distortions include selectively attending to one component of an event and ignoring other relevant aspects, or thinking in all or nothing terms. The original exposition of schema theory was not explicitly developed within the IP paradigm; the theory clearly implicates many cognitive processes including memory, attention, and perception. Furthermore, the theory states that schemas
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guide processing of incoming stimuli and influence perception and understanding, which in turn is translated in how people behave. However, neither the original exposition nor subsequent IP accounts of schema theory have provided a cogent model of how schemas guide IP and result in persistent emotional distress. It remains to be explained why a declarative belief such as ‘the world is a threatening place’ should result in heightened levels of anxiety and persistent worry. Schema theory remains a hugely influential and useful clinical theory, but has a number of conceptual limitations when considered from an explicit IP perspective. Notwithstanding this issue, the undoubted success of cognitive therapy continues to stimulate considerable research interest in the cognitive processes involved in the etiology and maintenance of clinical disorders. Cognitive behavior therapy (CBT) has become the predominant psychological treatment approach of the twenty-first century, having been extensively evaluated in over 400 randomized controlled trials and the breadth of application continues to grow. It is widely recognized that improvement in the efficacy of CBT approaches for specific disorders, such as social phobia, is a direct result of integrating schema and IP theories. Therefore, the IP paradigm will continue to flourish as it is assumed that further unraveling of cognitive processes, such as attentional biases in anxiety disorders, will enable increasingly effective interventions to be developed.
Significance of the IP Paradigm to Clinical Psychology The value of any paradigm resides in its ability to generate theories and well-specified models; the IP paradigm has excelled in this regard. There are a multitude of theories and associated models derived from the core assumptions of the IP paradigm across all subspecialities of clinical psychology. Within adult mental health, a multitude of generic and disorder-specific models exist, some drawing very specifically on the IP paradigm and others integrating components drawn from the IP paradigm with other schools of thought. Once models have been developed and empirically evaluated, the next step is to translate the models into effective psychological interventions and again work conducted under the IP paradigm has been extremely successful and has produced many highly differentiated treatments. Both of these core strengths of the IP paradigm can be illustrated with reference to posttraumatic stress disorder (PTSD). The central premise of many models of PTSD is that memory processes operate differently to normal memories as a consequence of the traumatic conditions in which the memories were encoded. For example, the dual representation theory proposes that different components of trauma memories are stored in different memory systems. Specifically, features of the traumatic experiences that are attended to consciously are stored in the verbally accessible memory (VAM) system and can be recalled easily. The nature of the beliefs in this system is hypothesized to be dysfunctional and represents common beliefs expressed by trauma patients, such as ‘I am to blame, it was my fault.’ In contrast, there are other aspects of the traumatic experience which were not consciously attended to, but were encoded in a situationally accessible memory (SAM). These memories are only recalled when triggered by a trauma cue and result in increased
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physiological reactivity, and reexperiencing symptoms. The model proposes that psychological treatment must correct information stored in both memory systems; therefore, cognitive restructuring methods are used to correct maladaptive beliefs, whereas exposure strategies are required to modify the physiological components of PTSD. In contrast to the models of PTSD, which specify a critical role for memory disorganization, the metacognitive model of PTSD proposes that metacognitive beliefs and processes are more important in maintaining PTSD than specific aspects of memory such as encoding and retrieval. Indeed, the metacognitive model argues that maintaining factors in PTSD relates to a particular processing style called the cognitive attentional syndrome (CAS). The CAS consists of high levels of perseverative thinking, threat monitoring, and coping behaviors that are guided by metacognitive beliefs and proceduralized knowledge that become active following the trauma experience and subsequent symptoms. Patients engage in high levels of worry because they hold positive metacognitive beliefs about the usefulness of worry as a coping strategy and also because they have negative metacognitive beliefs about the uncontrollable nature of worry. In relation to memory, an example of positive metacognitive belief would be ‘I must be remember all aspects of the trauma in order to move on,’ whereas negative metacognitive beliefs focus on the dangers and consequences of not being able to recall every aspect of the event. These two categories of metacognitive belief combine to keep the person focused on the threat and engage in continued processing of the trauma experience. Treatment would focus on the modification of positive and negative metacognitive beliefs about the CAS and would not involve cognitive restructuring of beliefs in the cognitive domain or use exposure exercises. These two examples illustrate the development and diversity of disorder-specific models that have been developed under the broad framework of the IP paradigm. Moreover, the two models highlight that the resultant treatments are distinct in how individuals with PTSD are assessed, conceptualized, and treated. The development of models within an IP framework has directly influenced diagnostic classificatory systems such as the International Classification of Disease (ICD) and Diagnostic and Statistical Manual (DSM). Since generalized anxiety disorder (GAD) entered the diagnostic taxonomy in 1980, it has undergone substantive changes. Originally, GAD was conceptualized primarily as a disorder of anxiety but with very limited reference to cognitive processes. In the latest incarnation of the Diagnostic and Statistical Manual (DSM-IV), the cardinal diagnostic feature of GAD is a cognitive process, namely excessive worry, which a person finds difficult to control. Such diagnostic changes are very significant as they provide both an impetus and direction for research. In the case of GAD, research is ever more focused on understanding the psychological processes which underpin worry. Panic disorder represents another clear illustration of how diagnoses for anxiety disorders have been shaped by research conducted under the IP rubric. Panic disorder is defined according to the psychological mechanisms responsible for the maintenance of the disorder. Patients with panic disorder catastrophically misinterpret symptoms of anxiety which is both the primary target for intervention and the cardinal feature of the disorder.
Evidently, clinical psychology has benefited from research conducted within the IP paradigm in many ways. In addition to the taxonomic, treatment, and model development, the IP framework continues to broaden its horizons as it is being applied to an increasing number of clinical problems. Furthermore, the IP approach is contributing to our understanding of vulnerability to relapse following treatment or indeed the genesis of clinical disorders as can be seen in the child psychopathology literature where research is providing illuminating data on potential pathways to emotional difficulties. Finally, evidence is steadily being accumulated that models and treatments located within an IP paradigm are producing increasingly more effective and time-efficient psychological treatments.
Emotional Disorders and Information Processing Biases A wealth of studies using a range of experimental tasks have demonstrated that people with elevated levels of anxiety demonstrate an attentional bias toward threatening stimuli compared to neutral stimuli. Such results are in accord with clinical accounts in which patients describe focusing their attention on signs of threats, for example internal sources such as unwanted thoughts and feelings or external signs of possible threat, typified by hypervigilence for signs of danger in PTSD patients. However, there may be both qualitative and quantitative difference in attentional allocation in the natural environment compared to laboratory experiments; this conundrum remains to be resolved. Nevertheless, research into biased IP in emotional disorders has made substantial advances over the past two decades. Early work in this area took a rather dichotomized approach to explain the IP biases observed in emotional disorders. For example, the majority of research found that anxiety disorders were characterized by selective attention toward threatening stimuli whereas affective disorders did not show this bias. Alternatively, depression and not anxiety was characterized by explicit memory biases toward self-relevant negative information. However, as the experimental paradigms and theorizing increased in sophistication, it has become evident that both anxiety and depression are characterized by a range of IP biases. Recent studies on depressed adolescents and on adults experiencing suicidal ideation have shown preferential attentional bias for self-relevant stimuli. A general finding is that the degree to which threatening stimuli are perceived as self-relevant is correlated with the magnitude of attentional bias. In PTSD, the interference effect observed on the emotional Stroop task is greater when the stimuli are most self-relevant; so, in combat veterans with PTSD, the interference effect will be greater for military stimuli than general trauma stimuli. A similar picture is seen in obsessive compulsive disorder, whereby biases are only observed when the stimuli are relevant to the individual specific obsessional concerns.
Components of Attentional Bias Attentional bias in anxiety comprise at least three components, which change according to the stage of IP. The first stage is facilitated attention, in which threatening stimuli are detected
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more rapidly than neutral or less threatening stimuli. The next stage is difficultly in disengaging from threat; in other words, anxious people find it difficult to shift their attention away from threatening stimuli; and the final stage is attentional avoidance, where people allocate their attention away from threatening stimuli. A broad range of experimental tasks (described below) have repeatedly demonstrated attentional bias at each stage of processing; however, the mediating mechanism(s) underpinning each component remains a source of controversy. Understanding the mechanisms responsible for attentional bias would facilitate the development of theoretically cogent and defined interventions.
Experimental Paradigms The emotional Stroop was the first task used extensively to measure attentional bias in anxiety. In this task, participants are presented with a series of threatening and neutral words printed in different colors and the objective is to name the color that each word is printed in as quickly as possible whilst ignoring the semantic content of the word. Response times are measured and differences in latencies of color-naming between threat words and neutral words are indicative of attentional bias. Across a range of anxiety disorders, studies using the emotional Stroop have found increased latencies of color-naming of threat words. The most frequent conclusion is that slower color naming is attributable to an automatic processing bias in anxiety which directs attention toward threatening material. However, the emotional Stroop has been the center of considerable debate for many years as numerous authors have argued that the mediating mechanism underpinning is not rapid orientation or engagement with threatening stimuli but instead primarily reflects a later stage of processing, namely difficulty engaging with threatening material. Researchers have also suggested that attempts by participants to suspend further processing of the threat cues slow colornaming. Other explanations for the interference effect on the emotional Stroop relate to the other cognitive and emotional processes involved in undertaking the task as it is not a pure measure of attention. It may be that participants process neutral and emotional stimuli to the same extent; however, the negative stimuli produce an increase in emotion which inhibits reaction time performance. This brief account of the emotional Stroop highlights that interpretation of the observed interference effect is highly problematic. Overall, evidence suggests that the interference effect is not attributable to just one component of attentional bias, and that the component which explains most of the effect appears to be difficultly disengaging from threat, rather than facilitated attention. An alternative task that has also been widely employed in assessing attentional bias toward threat and overcomes some of the limitations of the emotional Stoop is the dot probe task. This task is also thought to have greater ecological validity as it does not rely on words as stimuli and tends to use pictures that have personal meaning for the particular problem being investigated. For example, if a spider phobic was completing this task, then the neutral stimuli might be a range of everyday objects or animals that do not provoke distress, whereas the threatening picture would be relevant to the phobia. In this task, two pictures are presented simultaneously on a computer
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screen. The pictures then disappear and a probe replaces one of the pictures. Participants are asked to indicate as rapidly as possible (by a button press) which stimulus has been replaced by the probe. Attentional bias is inferred through faster responses to the probes that replace threatening stimuli relative to the neutral stimuli. A major advantage of the dot probe task is that the interval between stimulus presentation and the probe can be varied, enabling assessment of the time course of the attentional bias. Studies which have examined the effects of facilitated attention and difficulties in disengagement overwhelmingly find that the attentional bias effect is accounted for by delayed disengagement. This does not mean that a fast automatic orienting bias does not occur, but it does imply that the rapid orienting response is not contributing as significantly to the maintenance of anxiety disorders as early research indicated. Two other experimental tasks are frequently used to measure attentional biases. The visual search task allows assessment of spatial allocation of attention and speed of responding. Participants are asked to search for the target word amongst distractor words (as in a word search puzzle). A single threat word might be embedded in a matrix of neutral words and the reverse condition would ask participants to search for the neutral word amongst a set of self-relevant emotional words. Attentional bias is inferred from faster detection of threat words embedded in neutral words relative to detecting a neutral word embedded amongst other neutral words. The alternative condition is where participants are slower to detect neutral words in a matrix of threat words compared to detection of a neutral target word in a matrix of neutral stimuli. The final task that has been used frequently in attentional bias research is the spatial cueing task. In this task, the participant is asked to rapidly identify a target stimuli but they are cued (either by a neutral or threatening cue) to a spatial location on the computer screen before the target appears. The cue may be valid, in that the target appears in the same spatial location as the cue; alternatively, it may be invalid, in which case the target stimulus appears in a different spatial location to the cue. Attentional bias is inferred by faster response times for threatening cues in the correct spatial location or by slower response times on invalid trials. Both the visual search task and the spatial cueing task have produced robust results demonstrating attentional bias for threatening stimuli in a range of anxiety disorders, accounted for by difficulties in disengaging from threat. As experimental tasks have increased in sophistication and ability to measure the different components of attentional bias, the most robust finding is that people with elevated levels of anxiety have difficulty in disengaging from threatening stimuli. In other words, anxiety disorders are characterized by a lack of flexibility of allocation of attention. In the next section, the issue of whether attention is primarily an automatic or controlled process is discussed in more detail.
Automatic and Controlled Processing One of the most enduring theoretical disputes within IP accounts of emotional disorders and particularly in relation to attentional biases in anxiety is whether the observed bias is attributable to automatic or controlled processing. Automatic
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processing has been defined as uncontrollable, unintentional, unconscious, capacity free, and effortless, whereas controlled or strategic processing is an intentional, volitional process, which requires conscious awareness, effort and is constrained by capacity limitations. As IP accounts of anxiety were proposed during the course of the 1980s and 1990s, the distinction between controlled and automatic processing became highly significant because it determined how psychological treatments for anxiety were developed. If attentional and interpretative biases are automatic processes, then this implies that psychological therapies should focus on enabling patients to cope and manage with anxiety or possibly through extended retraining, attentional biases could be alleviated. The alternative view that attentional bias is primarily a product of controlled processing will result in a very different psychological intervention, as the focus would be on modifying processing configurations, guided by beliefs/knowledge which is stored in long-term memory structures. Examination of the automaticity of attentional biases in anxiety has moved away from a simple all-or-nothing dichotomy to exploring whether the different stages of processing are related primarily to automatic or controlled processing. The predominant view was, and continues to be, that facilitated attention represents an automatic process whereas the later stages of attentional bias (delayed disengagement and avoidance of threat) come increasingly under strategic control. However, research thus far has not unequivocally demonstrated that any stage of processing is either completely strategic or completely automatic. This is despite many studies concluding that attentional bias is an automatic process but this conclusion is unwarranted as these studies have generalized from an experimental task that has only manipulated one component of automaticity. For example, studies using the emotional Stroop have tried to determine whether the interference effect is attributable to an automatic process by using masked presentations. This task involves very brief presentation of the stimuli (<20 ms) and then the stimulus is masked for up to 480 ms before the next stimulus is presented. The idea behind this is that such rapid presentation prevents conscious awareness and therefore the observed interference effect reflects an automatic process. However, only degree of awareness has been manipulated and there is a question mark over the extent to which subliminal presentations with backward masking actually preclude conscious awareness. Therefore at best, studies have demonstrated that attentional biases are partially automatic, as no studies have successfully manipulated all facets of automaticity. This raises an important question, which is whether research focusing on differentiating automatic from controlled processing is meaningful or clinically useful as the majority of cognitive processes appear to be a combination of automatic and controlled processing. The more clinically useful question is determining whether strategic processing can exert an influence over the more automatic components of attentional bias. Theories differ in the importance placed on each stage of processing. Some theories emphasize that anxious people exhibit an enhanced automatic bias for threat during the early stages of processing and avoidance of threat in the later stages of processing, often labeled as the vigilance–avoidance model. Others have argued that the early stages of processing
and the automatic or rapid orienting response have little impact on anxiety, instead arguing that anxiety is maintained by a difficulty in disengaging from threat. As reviewed earlier in the article, the evidence from various analyses of experimental tasks would indicate that early components of attention are less important than later stage of processing in the maintenance of anxiety disorders.
Clinical Applicability of Information Processing Models and Treatments The ultimate test of the value of the IP approach is whether it has resulted in improved treatment efficacy as a result of translating theoretical advances into clinical treatments. The answer to this question depends on the treatment and disorder being investigated. Cognitive therapy for depression remains virtually unchanged in terms of treatment delivery and treatment efficacy over the past 30 years. Findings from empirical work on memory biases and attentional processes in depression have not been incorporated into cognitive therapy. The opposite is true for psychological treatments of anxiety disorders, where there are clear developments in the focus and nature of interventions for almost all anxiety disorders.
Cognitive Bias Modification Following on from research demonstrating that individuals with anxiety disorders show a preferential attention for threatening stimuli, it was argued that attentional bias was an integral component of anxiety disorders. Prospective studies found that facilitated attention bias was predictive of greater emotional reactivity to a stressful event. Furthermore, that when nonanxious people were trained to either direct their attention toward or away from threat, those individuals who were trained to orient toward threat showed significantly higher emotional responses to a stressor task. As a result of such studies, it was hypothesized that people suffering from an anxiety disorder could be trained to reduce their attentional bias toward threat. Therefore, cognitive bias modification (CBM) procedures, designed to decrease attentional bias in anxiety disorders, have been developed. It has been argued that CBM procedures may have an important role in the treatment of anxiety disorders, especially as the current level of efficacy of psychological treatments for many anxiety disorders is somewhat limited. CBM procedures typically involve a modification of the dot probe task and train people to orient rapidly away from threatening stimuli. Recent applications of CBM procedures in clinical samples have shown promising results including significant reductions in anxiety and depression in a GAD sample, after a 4-week training program. However, a number of issues require resolution. First, these procedures are predicated on the assumption that the early stage of attentional bias, facilitated attention toward threat, is being modified. However, it appears that the CBM procedures are operating at the later stages of attentive processing of threat, namely avoidance of threat. In other words, CBM techniques are modifying strategic rather than automatic processing. A related issue is that if people are being trained to look away from threat, then this has important clinical
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implications. Patients use avoidance to modulate anxiety, but with an important consequence, they do not learn more effective methods of responding to threat. A further issue with the CBM results is that although GAD patients showed reductions in overall levels of anxiety and depression, the cardinal feature of GAD, namely worry, remained comparatively unchanged. Studies such as these highlight that modifying attentional processes may result in reductions of anxiety, but anxiety disorders are not only characterized by attentional biases and other important aspects of the disorder remain unchanged. Further research is required to delineate the mechanism of action, especially as it is possible that these training procedures are actually counterproductive in the long run. Despite the need to clarify these issues, the recent studies on CBM raise a number of fascinating possibilities including whether the strategies can be successfully incorporated in existing CBT protocols with a resultant increase in treatment efficacy.
The Self-Regulatory Model of Executive Dysfunction in Emotional Disorders One model that has been developed within an IP framework to explain the persistence of emotional disorders is the Self-Regulatory Executive Function model (S-REF). This model was proposed by Adrian Wells and Gerald Matthews as a transdiagnostic understanding of the factors involved in the maintenance of psychological disorder. The model attempted to overcome some of the limitations of schema theory and develop a model of psychopathology that was explicitly developed within the IP framework. The model specifies that psychological disorders should be conceptualized as predominantly top-down or conscious processes, with a set of self-regulatory strategies. According to the model, a particular style of thinking and coping with negative thoughts and feelings results in the exacerbation and maintenance of emotional distress. This particular style of thinking has been termed the CAS and consists of perseverative thinking, threat monitoring, and counterproductive coping strategies. In developing the model, the authors returned to earlier work on attention, which specified that there were different levels of control in the form of automatic and controlled processing. The S-REF model proposes that emotional distress is linked primarily to biases in the selection and execution of controlled processes for appraising and coping with intrusive cognitive and emotional events. More specifically, an individual’s strategy for thinking and self-regulation in response to unwanted thoughts and feelings can either intensify and maintain negative emotions or result in brief emotional reactions. Emotional disorders such as anxiety and depression occur when the style of thinking and coping inadvertently leads to persistence and strengthening of emotional responses. The CAS is guided by metacognitive beliefs concerning (a) the benefits of engaging in each aspect of the CAS, for example ‘worry helps me cope’ and (b) the uncontrollable nature of the CAS, for example ‘my worry is out of my control, I cannot stop myself from worrying.’ In MCT, the CAS and the supporting metacognitive beliefs are the psychological processes that are targeted in therapy.
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In contrast to cognitive therapy and CBM approaches, metacognitive theory does not link psychological problems to automatic processing biases or the content of schemas. Instead, metacognitive theory specifies that psychological problems are attributable to conscious and volitional strategies. In relation to the experimental paradigms used to assess attentional bias earlier in the article, metacognitive theory does not link the observed effects to activation of schemas or automatic processing but attributes them to strategy selection. In anxiety disorders, patients have a strategy of maintaining attention on sources of threat and engaging in worry-based processing as a means of coping. The S-REF model is based on three basic levels of cognition: a level of reflexive and automatic processes that run with minimal or no conscious involvement. These processes may generate intrusions into consciousness that capture attention. The next level is an online form of processing which is conscious and capacity-limited, responsible for regulating and implementing appraisal and action. The final level is stored knowledge in long-term memory. The immediate activities of the online processing require access to stored knowledge in order to run. Online processing is guided by knowledge or beliefs that are metacognitive in nature. In line with one of the core values of the IP approach, the S-REF theory has generated many disorder-specific models, including models of depression, GAD, PTSD, social phobia, and obsessive compulsive disorder. Current research is evaluating the applicability of the S-REF model in an even broader range of issues such as alcoholism, psychosis, and persistent distress in survivors of cancer and myocardial infarctions. Evaluation of treatment efficacy of metacognitive therapy is in the early stages, but it is producing very high recovery rates across a range of clinical disorders.
Conclusions IP models proliferate in clinical psychology, but the disparate nature of the underpinning theories leads to very different treatment approaches. This is a strength of the IP approach as it provides clinical psychology with a rich theoretical basis, from which further advancements can be achieved. The generation of novel interventions in the form of CBM strategies and metacognitive approaches are exciting innovations that hold considerable promise for the continually evolving practice of clinical psychology. In summary, the IP paradigm has resulted in a wealth of research and clinical developments that ultimately result in significant therapeutic benefits.
See also: Anxiety and Fear; Anxiety Disorders; Attention; Cognitive Behavior Therapy; Cognitive Bias.
Further Reading Amir N, Burns M, Beard C, and Bomyea J (2009) Attention modification program in individuals with generalized anxiety disorder. Journal of Abnormal Psychology 118(1): 28–33.
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Bar Haim Y, Lamy D, Pergamin L, Bakermans-Kranenberg M, and van Ijzendoorn M (2007) Threat-related attentional bias in anxious and nonanxious individuals: A meta-analytic study. Psychological Bulletin 133: 1–24. Beck AT (1976) Cognitive Therapy and the Emotional Disorders. New York: International Universities Press. Beck AT and Clark DA (1997) An information processing model of anxiety: Automatic and strategic processes. Behavior Research and Therapy 35: 49–58. Brewin CR, Dalgleish T, and Joseph S (1996) A dual representation theory of posttraumatic stress disorder. Psychological Review 103(4): 670–686. Cisler J and Koster E (2010) Mechanisms of attentional bias toward threat in anxiety disorders: An integrative review. Clinical Psychology Review 30: 203–216. Flavell JH (1979) Metacognition and metacognitive monitoring: A new area of cognitive-developmental inquiry. American Psychologist 34: 906–911. Hankin BL, Abela J, Gibb BE, and Flory K (2010) Selective attention to affective stimuli and clinical depression among youths: Role of anxiety and specificity of emotion. Journal of Abnormal Psychology 119: 491–501.
Ingram RE (1990) Self-focused attention in clinical disorders: Review and conceptual model. Psychological Bulletin 107: 156–176. Lachman R, Lachman JL, and Butterfield EC (1979) Cognitive Psychology and Information Processing: An Introduction. Hillsdale, NJ: Erlbaum. Mathews A and MacLeod C (2005) Cognitive vulnerability to emotional disorders. Annual Review of Clinical Psychology 1: 167–195. Phaf RH and Kan K (2007) The automaticity of emotional Stroop: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry 38: 184–199. Wells A (2000) Emotional Disorders and Metacognition: Innovative Cognitive Therapy. Chichester, UK: Wiley. Wells A and Matthews G (1996) Modeling cognition in emotional disorder: The S-REF Model. Behavior Research and Therapy 34(11): 881–888. Williams JMG, Watts FN, MacLeod C, and Mathews A (1988) Cognitive Psychology and Emotional Disorders. Chichester, UK: Wiley.