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Rumination and social problem-solving in depression
Behaviour Research and Therapy 40 (2002) 1179–1189 www.elsevier.com/locate/brat
Rumination and social problem-solving in depression Ed Watkins *, Simona Baracaia Department of Psychology, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK 8 October 2001
Abstract We tested the hypothesis that impaired social problem solving in depression is a consequence of stateoriented rumination, which can be ameliorated by improving awareness of mental processes. 32 currently depressed, 26 recovered depressed, and 26 never depressed participants completed the Means Ends Problem Solving Test while randomly allocated to no questions, state-oriented ruminative questions, (e.g. focusing on why you have a problem) or process-focused questions (e.g. focusing on how you decide to solve a problem). In the no question condition, the currently depressed group was significantly impaired at problem solving compared to the never depressed and recovered depressed groups, which did not differ from each other. As predicted, the process-focused questions significantly improved social problem solving in depressed patients, compared to no questions and state-oriented questions, which did not differ from each other. As predicted, compared to the process-focused questions, the state-oriented questions significantly impaired social problem solving in the recovered depressed group. These results are consistent with recent theories and treatment developments which suggest that increased awareness of mental processes can shift people away from ruminative thinking, thereby, reducing depressive relapse. 2002 Elsevier Science Ltd. All rights reserved. Keywords: Depression; Rumination; Problem solving; Mindfulness
1. Introduction Deficits in social problem solving have been suggested as a core feature of depression (e.g. Beck, 1976; Nezu, 1987), with poor problem solving considered a moderator between the occurrence of stressful life events (e.g. Nezu & Ronan, 1985) and the onset of depression. Depressed patients rate themselves as more ineffective at problem solving (Heppner, Baumgardner, & Jackson, 1985) and show problem solving deficits on objective measures such as the Means Ends * Corresponding author. Tel.: +44-207-848-3226; fax: +44-207-848-5006. E-mail address: [email protected] (E. Watkins).
0005-7967/02/$ - see front matter 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 0 1 ) 0 0 0 9 8 - 5
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Problem Solving Task (MEPS; Platt & Spivack, 1975) compared to controls and anxious patients (Goddard, Dritschel, & Burton, 1996; Marx, Williams, & Claridge, 1992). Furthermore, problemsolving therapy (Nezu, Nezu, & Perri, 1989) produces significant clinical improvements, indicating that problem solving ability influences the prognosis of depression. Recent studies (Lyubomirsky & Nolen-Hoeksema, 1995; Lyubomirsky, Tucker, Caldwell, & Berg, 1999) suggest that rumination may impair problem solving in depression. Nolen-Hoeksema (1991) defined rumination as a response style that involves focusing on and thinking about the causes, consequences and meanings of depressed mood. Research has suggested that people differ in their personal dispositions towards this response style (Nolen-Hoeksema, Morrow, & Fredrickson, 1993), and, furthermore, that the response style can be manipulated by inductions that focus or distract attention from mood state (Nolen-Hoeksema & Morrow, 1993). Dysphoric participants who ruminated on the causes and consequences of their mood were significantly impaired at interpersonal problem solving on the MEPS compared to dysphoric participants who distracted themselves from their mood or non-dysphoric participants in either induction (Lyubomirsky & Nolen-Hoeksema, 1995; Lyubomirsky et al., 1999). Since patients with current and past major depression ruminate significantly more than never-depressed controls, (Roberts, Gilboa, & Gotlib, 1998) rumination may account for the problem solving deficits in depression. Kuhl (1981, 1994) conceptualized rumination as analytical thinking about the causes and consequences of internal states (e.g. mood) and external states (e.g. problems) that had become an end in itself, rather than a means to effective action. In Kuhl’s theory, rather than reflecting a response style, rumination is one aspect of a broader impairment in volitional control called “state orientation”. State orientation is characterized by preoccupation with simulating alternative plans and by the analysis and evaluations of past successes and failures, producing difficulties in initiating new actions. Kuhl also proposed an action orientation, which involves effective volitional control, and is characterized by action planning and effective self-monitoring. People show personal dispositions towards state or action orientation, with State-oriented but not Action-oriented participants more vulnerable to depressive symptoms (Rholes, Michas, & Shroff, 1989). However, the orientations can be manipulated by brief inductions: Explicitly stating hypotheses during a reasoning task removed the performance deficits normally found in State-oriented participants following uncontrollable failure (Kuhl, 1981). By integrating Kuhl’s (1981) account with the findings of Lyubomirsky and colleagues, we hypothesised that impaired social problem solving in depression is a consequence of state-oriented rumination, which can be ameliorated by inducing an action orientation. This account predicts that it is not just the content of thinking (e.g. not thinking about negative mood, i.e. distraction, versus thinking about negative mood, i.e. rumination) that influences problem solving but also the particular style of thinking adopted. Thus, the aim of this study was to test the hypothesis that the thinking style adopted when considering a problem influences the effectiveness of problem solving. To test this hypothesis, this study compared the effects of state-oriented questions, actionoriented questions and no questions during problem solving on the MEPS in currently depressed, recovered depressed and never-depressed groups. In contrast to Lyubomirsky and Nolen-Hoeksema (1995) and Lyubomirsky et al. (1999), who compared the effects of rumination and distraction prior to thinking about an interpersonal problem, this study manipulated participants’ cognitive style when they were thinking about an interpersonal problem. Furthermore, we specifically included a clinically depressed group because Lyubomirsky and colleagues had only used dysph-
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oric students, concluding that “the effects of focusing manipulations on the thinking and problem solving of clinically depressed individuals are largely unknown” (Lyubomirsky et al., 1999, p. 1058). We also included a recovered depressed group to investigate whether problem-solving deficits depend on depressed state or reflect an underlying vulnerability factor. Increased awareness in the here and now is a core aspect of action orientation (Kuhl & Kazen, 1994) and effective action-oriented inductions involve increasing awareness of mental processes (e.g. explicitly stating reasoning hypotheses, Kuhl, 1981). We therefore used questions focusing on the mental process of problem solving as our action orientation condition. Interestingly, the process-focused aspect of action orientation parallels recent theoretical work, which suggests that increasing awareness of thoughts and feelings in the present moment can help treat depression (Teasdale & Barnard, 1993; Teasdale, Segal, & Williams, 1995). Mindfulness-based Cognitive Therapy (MBCT), derived from this theory, uses attentional exercises to increase awareness of thoughts and feelings and significantly reduced depressive relapse over 1 year in recurrent depressed patients, compared to treatment-as-usual (Teasdale et al., 2000). We predicted that currently depressed participants would show general deficits in problem solving compared to never depressed participants, replicating Marx et al. (1992). We predicted that there would be no significant difference in problem solving between state-oriented questions and the no question condition in currently depressed participants, because we expected the currently depressed group to habitually choose a state orientation. Consistent with the hypothesis that increased awareness of mental process improves problem solving, we predicted that the process-focused questions would improve problem solving in the currently depressed group. Consistent with the hypothesis that rumination impairs problem solving, we predicted that the stateoriented questions would impair problem solving compared to the no question and process-focused conditions in the recovered depressed group. Kuhl (1994) proposed that the negative effects of state orientation are only manifest following appropriate setting conditions, such as failure, just as Nolen-Hoeksema (1991) proposed that rumination is only dysfunctional in a dysphoric mood. We therefore predicted that state-oriented rumination would not significantly influence problem solving in the never depressed group. We made no specific predictions about the effect of the process-focused questions in the never depressed group. 2. Method 2.1. Design We used a 3 (Group: currently depressed, recovered depressed, never depressed) ×3 (Condition: no questions, state-oriented questions, process-focused questions) mixed factors design. Participants were randomly allocated to the conditions (no questions, n=27; state-oriented, n=29; process-focused, n=28; cell sizes from 7-11 participants). 2.2. Participants 2.2.1. Currently depressed group (n=32) We recruited 24 women and 8 men (age range 18–65, M=42.3, SD=12.8) meeting criteria for current major depressive disorder (DSM-IIIR, American Psychiatric Association, 1987) on the
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Structured Clinical Interview for DSM-IIIR (SCID; Spitzer, Williams, Gibbon, & First, 1990), from inpatient and outpatient settings. Beck Depression Inventory (BDI; Beck, Rush, Shaw, & Emery, 1979) scores ranged from 16 to 39 (M=25.3, SD=6.5). The mean score on the Ruminative Response Scale (RRS; Nolen-Hoeksema & Morrow, 1991) was 65.0 (SD=11.0). 81.2% were prescribed antidepressants. Co-morbid diagnoses were eating disorder (3.3%), anxiety disorder (28.1%) and alcohol or substance abuse (12.5%). The current depression lasted on average 8.7 months (SD=9.2), mean age of first onset was 21.5 years (SD=8.3) and the number of previous depressions was 6.2 (SD=3.4) (“too many to count” coded as 10). 2.2.2. Recovered depressed group (n=26) We recruited 18 women and 8 men (age range 29–64, M=41.8, SD=9.9), meeting criteria of no current major depression but at least one past major depression on the SCID, and a BDI score of 14 or less (M=7.2, SD=3.8), from a self-help charity for depression. 15.4% were prescribed antidepressants. Other diagnoses were anxiety disorder (11.5%) and past alcohol or drug abuse (11.5%). The mean RRS score was 47.7 (SD=14.5). The age of first onset was 27.6 years (SD=12.9) and the number of previous depressions was 3.1 (SD=2.6). 2.2.3. Never depressed group (n=26) We recruited 16 women and 10 men (age range 20–63, M=36.1, SD=12.2), meeting criteria of no diagnosis of major depression or dysthymia in the present or past on the SCID, and a current BDI score of 14 or less (M=3.8, SD=3.8). None were currently prescribed antidepressants. The mean RRS score was 36.5 (SD=8.2). A Chi-squared test found no significant differences between the Groups in the relative proportions of men and women (p=0.54). Separate 3 (Group) ×3 (Condition) analyses of variance (ANOVAs) found a significant Group effect on BDI scores, F(2,75)=147.0, p⬍0.0001, and on RRS scores, F(2,75)=47.6, p⬍0.0001 (one case missing data). As expected, post hoc Scheffe´ Tests showed that the currently depressed group had significantly higher BDI and RRS scores than the recovered depressed and never depressed groups (p⬍0.001 for all tests). The recovered depressed group was nearly significantly more depressed (p=0.059) and had significantly higher rumination scores than the never depressed group (p⬍0.001). There were no other significant main effects or interactions on BDI or RRS, all F’s ⬍1. 2.3. Materials 2.3.1. Mood measure Participants rated their current mood on an 0–100 scale ranging from 0 I do not feel at all despondent to 100 I feel extremely despondent (Teasdale, Taylor, & Fogarty, 1980). 2.3.2. Beck Depression Inventory The BDI (Beck et al., 1979) is a 21-item self-report measure of symptoms of depression, with good psychometric properties (Beck, Steer, & Garbin, 1988).
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2.3.3. The Ruminative Response Scale (RRS) The RRS is a 22-item self-report measure of how often respondents respond to a sad mood with rumination, with good internal consistency and validity (Nolen-Hoeksema & Morrow, 1991). 2.3.4. Means-Ends Problem-Solving test The MEPS measures the ability to conceptualise step-by-step means (strategies) of achieving a goal. For each MEPS situation, the participant is presented with the beginning and end of a problem. Participant’s answers are scored for the number of discrete steps that are effective in enabling the subject to reach the goal or overcome an obstacle. The MEPS has satisfactory internal consistency (from 0.80 to 0.84) and construct validity (e.g. Platt & Spivack 1972, 1975). This study used a shortened version of the MEPS, consisting of situations 2, 4, 8 and 10, following a precedent adopted by Marx et al. (1992) and Lyubomirsky and Nolen-Hoeksema (1995). These items assess problem solving with respect to different life areas (argument with your partner, difficulty with your boss, a friend avoiding you, making new friends). This study used scenarios worded in the second person, replicating Lyubomirsky and Nolen-Hoeksema (1995) and Lyubomirsky et al. (1999), and asked participants to find the ideal strategy for overcoming the problem situation (Marx et al., 1992). The experimenter read the situations to the participants, who simultaneously followed them on separate index cards. Participant’s answers were noted verbatim. There was no time limit for the task. We measured the time spent to complete each problem. 2.3.5. State-oriented and process-focused conditions In both conditions, participants were instructed to bear in mind seven questions presented on an index card as they tried to think of the best solution to each scenario. The state-oriented questions were naturally occurring questions reported by dysphoric ruminators (Watkins & Baracaia, 2001) that focused on the causes of problems (Kuhl, 1981; Nolen-Hoeksema, 1991). The state-oriented questions were: “What am I doing wrong?”; “What caused this problem?”; “Why can’t I do better?”; “What is the reason behind all this?”; “What’s wrong here?”; “Why can’t I get things right?”; and “How can I understand this?”. The process-focused questions were designed to increase awareness of the mental processes involved in problem solving, and were adapted from questions that improved solution performance on a logical task in non-depressed participants (Berardi-Coletta, Buyer, Dominowski, & Rellinger, 1995). Questions were: “How am I deciding on a way to solve this problem?”; “How am I deciding what to do next?”; “How do I know this is a good thing to do?”; “How am I deciding what might prevent success?”; “What am I thinking about in terms of starting to solve this problem?”; “How do I decide whether my plan needs to be changed?”; and “How do I decide whether that was a useful step towards a solution?”. 2.4. Procedure All of the participants were interviewed using the SCID, and then randomly allocated to one of the three conditions. Participants completed the BDI, RRS, and despondency scale, before the MEPS task was explained to them. In the no question condition, participants completed the MEPS without being presented any extra information. For each problem scenario, participants in the
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state-oriented and process-focused conditions were asked to review the questions on the index card whilst they solved the problem. Following the MEPS, participants rated their despondency again. 2.5. Scoring of the MEPS responses A judge unaware of group or condition scored all responses for number of relevant means and for their effectiveness, using a 7-point Likert-type scale ranging from 1 (not at all effective) to 7 (extremely effective) (e.g. Lyubomirsky & Nolen-Hoeksema, 1995; Marx et al., 1992). A strategy was considered effective if it maximised positive and minimised negative short and longterm consequences (D’Zurilla & Goldfried, 1971). An independent second judge, unaware of group or condition, rated a random 10% selection of all responses, with high interrater reliability (relevant means, r=0.76; effectiveness, r=0.79). 3. Results An alpha level of 0.05 was used for all statistical tests. All analyses were initially performed with sex of participant as a between-subjects factor. There were no significant main effects or interactions with sex of participant; therefore, all analyses reported were conducted by collapsing across sex of participant. 3.1. Group and condition differences in relevant means and effectiveness We analysed the total number of relevant means and the mean effectiveness of problem solving in separate 3 (Group) ×3 (Condition) ANOVAs.1 Figure 1 displays the pattern of relevant means for all groups and conditions (the pattern of results was equivalent for the effectiveness ratings; for economy, only relevant means are displayed). There was a significant main effect of Group, for number of relevant means, F(2,75)=8.3, p⬍0.001 and for effectiveness, F(2,75)=7.3, p⬍0.001. We found a significant main effect of Condition, for number of relevant means, F(2,75)=4.3, p⬍0.02 and for effectiveness, F(2,75)=3.3, p⬍0.05. These main effects were qualified by significant Group × Condition interactions for both the number of relevant means, F(4,75)=3.4, p⬍0.05, and for the ratings of effectiveness, F(4,75)=3.0, p⬍0.03. These interactions were still significant when the analyses were repeated with time to complete problems as a covariate (n=69); relevant means, F(4,59)=2.8, p⬍0.05 and effectiveness, F(4,59)=2.9, p⬍0.03. In order to examine the interactions further, we performed a series of separate ANOVAs within To check that participants had engaged in the appropriate style of thinking during each condition, 3 (Group) ×3 (Condition) ANOVAs were calculated for the number of statements during problem solving that directly reflected state-oriented questions and process-focused questions, respectively. A judge, unaware of group and condition, counted the statements, with high interrater reliability (state-oriented, r=0.962; process-focused, r=0.986), with a second independent judge, who rated a random 20% selection of responses. There were significantly more state-oriented responses (M=3.9, SD=2.8) in the state-oriented condition than in the process-focused (M=0.89, SD=1.03) or no question conditions (M=0.78, SD=0.85), F(2,75)=24.6, p⬍0.001. There were significantly more process-focused responses in the process-oriented condition (M=2.9, SD=2.6) than in the state-oriented (M=0.14, SD=0.58) and no question conditions (M=0.01, SD=0.38), F(2,75)=30.2, p⬍0.001. 1
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Fig. 1. Number of relevant means by group and by condition (error bars represent standard deviations).
each Condition, with Group as the independent variable, and within each Group, with Condition as the independent variable, using relevant means and effectiveness as our dependent variables. Scheffe´ tests were used for the post hoc comparisons in order to reduce the risks of Type 1 errors (Ferguson, 1976). Within the no question condition, there was a significant main effect of Group on the number of relevant means, F(2,24)=7.2, p⬍0.005 and on effectiveness, F(2,24)=6.8, p⬍0.005. Scheffe´ tests indicated that the currently depressed group produced significantly fewer relevant means (p⬍0.01) than the recovered depressed or the never depressed groups (p⬍0.05), which did not significantly differ from each other (p=0.997). The currently depressed group produced significantly less effective solutions than the recovered depressed group (p⬍0.01) and less effective solutions than the never depressed group (p=0.059). Within the state-oriented condition, there was a significant main effect of Group on the number of relevant means, F(2,26)=8.4, p⬍0.001 and on effectiveness, F(2,26)=5.8, p⬍0.01. The currently depressed group produced significantly fewer relevant means (p⬍0.005) and less effective solutions (p⬍0.015) than the never depressed group. The recovered depressed group also produced significantly fewer relevant means (p⬍0.02) and less effective solutions (p⬍0.05) than the never depressed group, whilst not differing from the currently depressed group on number of relevant means (p=0.92) or effectiveness (p=0.96). Within the process-focused condition, there was not a significant main effect of Group on relevant means, F(2,25)=1.1, p=0.34, or on effectiveness, F(2,25)=1.2, p=0.32. Within the never-depressed group, there was not a significant main effect of Condition on relevant means, F(2,23)=0.68, ns, or on effectiveness, F (2,23)=0.35, ns. Within the recovered depressed group, there was a significant main effect of Condition on relevant means, F(2,23)=3.9, p⬍0.05 and on effectiveness, F(2,23)=4.0, p⬍0.05. Compared to the process-focused condition, the state-oriented condition produced fewer relevant means (p⬍0.05) and less effective solutions (p⬍0.05). There was no significant difference in number of
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means produced (p=0.21) or effectiveness (p=0.11) between the state-oriented condition and the no question condition or between the process-focused condition and the no question condition (p=0.57). Within the currently depressed group, there was a significant main effect of Condition on relevant means, F(2,29)=6.31, p⬍0.005 and on effectiveness, F(2,29)=5.53, p⬍0.05. Scheffe´ tests indicated that the process-focused condition had significantly more relevant means than the no question condition (p⬍0.01) and the state-oriented condition (p⬍0.05), which did not differ from each other (p=0.717). Similarly, the process-focused condition produced more effective solutions than the no question condition (p⬍0.02) and approached significance for producing more effective solutions than the state-oriented condition (p=0.089). 3.2. Group and condition differences in dysphoric mood As a test of baseline levels of dysphoric mood, we calculated a 3 (Group) ×3 (Condition) ANOVA with baseline despondency as the dependent variable. There was a main effect of Group, F(2,75)=39.4, p⬍0.001. Post hoc Scheffe´ tests indicate that the currently depressed group was significantly more despondent (M=62.0, SD=19.6) than the recovered depressed group (M=21.2, SD=21.1, p⬍0.001) and the never depressed group (M=19.5, SD=19.7, p⬍0.001) which did not differ from each other (p=0.94). There were no differences in baseline despondency between conditions, F(2,75)=0.20, ns, and the interaction between group and condition was not significant, F(4,75)=0.25, ns. We calculated a 3 (Group) ×3 (Condition) ANOVA with despondency following the MEPS task as the dependent variable, to test whether the variables influenced dysphoric mood. The significant main effect of Group, F(2,74)=34.9, p⬍0.001, was replicated, but there was no other significant main effects or interactions, all Fs ⬍1, i.e., the manipulations did not alter despondent mood. 4. Discussion The aim of this study was to investigate whether the cognitive style adopted when thinking about a problem could influence the outcome of problem solving in depressed people. Specifically, we hypothesised that impaired social problem solving in depression is a consequence of stateoriented rumination, which can be ameliorated by process-focused thinking. We found that manipulating cognitive style during problem solving systematically influenced success at problem solving in a pattern consistent with this hypothesis. First, manipulating orientation towards problems had no effect on the problem solving of the never-depressed group. The never-depressed participants were competent at solving problems in all three conditions. Second, in both the recovered depressed and currently depressed groups, thinking style during problem solving did significantly influence problem-solving outcome. As predicted, the processfocused questions produced significantly more relevant means and more effective solutions than the state-oriented questions in both clinical groups. In the no question condition, the currently depressed group were significantly impaired at problem solving compared to the never depressed group, replicating Marx et al. (1992). Nonetheless, the benefits of the process-focused questions
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were so substantial that in this condition currently depressed patients were as successful at problem solving as the never-depressed group. As predicted, process-focused thinking ameliorated the problem-solving deficit in depression. Conversely, in the state-oriented condition, the recovered depressed patients were as poor at problem solving as currently depressed patients, despite solving problems as well as the never-depressed group in the no question and process-focused conditions. This result suggests that the state-oriented questions impaired problem solving performance in recovered depressed patients, although there was no significant difference between the no question condition and the state-oriented condition in the recovered-depressed group. The current findings provide some evidence that rumination can impair problem solving in clinically relevant groups (Judd, 1997), as well as dysphoric students. Third, the inclusion of the no question condition allowed us to make some inferences about the habitual thinking style adopted by default for problem solving in the clinical groups. The lack of a significant difference in problem solving between the no question condition and the stateoriented condition in the currently depressed group is consistent with our hypothesis that depressed patients habitually choose a state orientation if left to their own devices. The pattern of results for the recovered depressed group is consistent with their habitual style being intermediate between the currently depressed and never depressed groups. These hypotheses are consistent with self-reported patterns of rumination (Nolen-Hoeksema, 2000; Roberts, Gilboa, & Gotlib, 1998): depressed patients report significantly more rumination than recovered depressed patients, who in turn, report significantly more rumination than never depressed people. Previous studies of rumination (e.g. Nolen-Hoeksema & Morrow, 1993) found elevated levels of depressed mood following the rumination induction compared to the distraction induction in dysphoric participants. In contrast, we did not find elevated levels of despondent mood in the state-oriented rumination condition compared to the other conditions for any group. The differential effects of the state-oriented and process-focused questions seem to be unrelated to changes in mood. As noted earlier, this study examined the effects of thinking style during problem solving, rather than the effects of distraction or rumination about dysphoric mood prior to problem solving. This change in methodology might account for the difference in mood effects: NolenHoeksema (1991) posited that rumination about dysphoric mood was necessary for exacerbation of negative mood, whilst in this study, participants ruminated about arbitrary interpersonal problems. Nonetheless, the process-oriented condition might be expected to improve mood because of its beneficial effect on problem solving. Clearly, for real-life problems, improved problem solving would be expected to improve mood. However, the MEPS problems were arbitrary and imaginary such that solving them should not impact on participants’ lives and, thus, would not be expected to improve mood. The pattern of results suggests that depressed patients adopt a style of thinking that impairs their ability to solve interpersonal problems. Furthermore, these findings suggest that one possible mechanism of relapse in recovered depressed patients is state-oriented responses to a stressful life event leading to impaired social problem solving and further escalation of the stressful situation (Nezu & Ronan, 1985). More pertinently, it was possible to shift currently depressed patients to a more effective problem solving style, at least over the brief time-course of this study, by using process-focused questions. The limitations of this study, of course, were that we could not ascertain how long an induced action orientation would persist, nor do we know whether the manipulations would influence solution generation to personally relevant, real-life problems.
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Given the construct validity of the MEPS (Platt & Spivack, 1975), sustaining this shift in thinking style in a more enduring way would, presumably, help to maintain effective interpersonal problem solving in both current and recovered depressed patients, with ramifications for treatment and relapse prevention (e.g. Nezu et al., 1989). The ability of current psychological treatments to produce an enduring shift into a processfocused orientation is not known. Although neither cognitive therapy (Beck, 1976) nor problem solving therapy (Nezu et al., 1989) explicitly focus on encouraging a process-focused orientation, aspects of these therapies (e.g. thought monitoring, problem definition) may implicitly do so. As discussed earlier, MBCT does explicitly encourage increased awareness of thoughts in the present moment through the use of daily attentional exercises. Thus, encouraging a process-focused orientation rather than a state-orientation in recovered depressed patients, and, thereby, facilitating effective interpersonal problem solving may be one potential mechanism by which MBCT reduces depressive relapse. Future research could usefully examine whether process-focused thinking plays a role in effective therapy and investigate how we can systematically induce an enduring process orientation in patients. In conclusion, the current results replicate the finding that people with current major depression are impaired at social problem solving and are consistent with the hypothesis that state-oriented rumination determines this deficit. The impaired problem solving found for recovered depressed people in the state-oriented condition suggests that rumination can impair problem solving in a clinical sample and suggests a potential mechanism of depressive relapse. A process-focused condition improved problem solving in currently depressed patients, consistent with the hypothesis that inducing action-oriented responses improves problem solving. Acknowledgements This study was supported by a grant to Edward Watkins from the Lesley Ann Smith fund, Psychiatry Research Trust. References American Psychiatric Association, (1987). Diagnostic and Statistical Manual of Mental Disorders. (3rd ed revised). Washington, DC: American Psychiatric Association. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford Press. Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twentyfive years of evaluation. Clinical Psychology Review, 8, 77–100. Berardi-Coletta, B., Buyer, L. S., Dominowski, R. L., & Rellinger, E. R. (1995). Metacognition and problem solving: A process-oriented approach. Journal of Experimental Psychology: Learning, Memory and Cognition, 21, 205–223. D’Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification. Journal of Abnormal Psychology, 78, 107–126. Ferguson, G. A. (1976). Statistical analysis in psychology and education. Tokyo: McGraw-Hill. Goddard, L., Dritschel, B., & Burton, A. (1996). Role of autobiographical memory in social problem solving and depression. Journal of Abnormal Psychology, 105, 609–616. Heppner, P. P., Baumgardner, A., & Jackson, J. (1985). Problem-solving self-appraisal, depression, and attributional style: Are they related? Cognitive Therapy and Research, 9, 105–113.
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Judd, L. J. (1997). The clinical course of unipolar major depressive disorders. Archives of General Psychiatry, 54, 989–991. Kuhl, J. (1981). Motivational and functional helplessness: The moderating effects of state versus action orientation. Journal of Personality and Social Psychology, 40, 155–170. Kuhl, J. (1994). A theory of action and state orientations. In J. Kuhl, & J. Beckmann (Eds.), Volition and personality. Action- and state-oriented modes of control (pp. 9–46). Seattle, Gottingen: Hogrefe. Kuhl, J., & Kazen, M. (1994). Volitional aspects of depression: State orientation and self-discrimination. In J. Kuhl, & J. Beckmann (Eds.), Volition and personality. Action- and state-oriented modes of control (pp. 297–315). Seattle, Gottingen: Hogrefe. Lyubomirsky, S., & Nolen-Hoeksema, S. (1995). Effects of self-focused rumination on negative thinking and interpersonal problem solving. Journal of Personality and Social Psychology, 69, 176–190. Lyubomirsky, S., Tucker, K. L., Caldwell, N. D., & Berg, K. (1999). Why ruminators are poor problem solvers: clues from the phenomenology of dysphoric rumination. Journal of Personality and Social Psychology, 77, 1041–1060. Marx, E. M., Williams, J. M. G., & Claridge, G. C. (1992). Depression and social problem solving. Journal of Abnormal Psychology, 101, 78–86. Nezu, A. M. (1986). Cognitive appraisal of problem-solving effectiveness: Relation to depression and depressive symptoms. Journal of Clinical Psychology, 42, 42–48. Nezu, A. M. (1987). A problem-solving formulation of depression: A literature review and proposal of a pluralistic model. Clinical Psychology Review, 7, 121–144. Nezu, A. M., Nezu, C. M., & Perri, M. G. (1989). Problem-solving therapy for depression: Theory, research and clinical guidelines. New York: Wiley. Nezu, A. M., & Ronan, G. F. (1985). Life stress, current problems, problem-solving, and depressive symptoms: An integrative model. Journal of Consulting and Clinical Psychology, 53, 693–697. Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100, 569–582. Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology, 109, 504–511. Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. Journal of Personality and Social Psychology, 61, 115–121. Nolen-Hoeksema, S., & Morrow, J. (1993). Effects of rumination and distraction on naturally occurring depressed mood. Cognition and Emotion, 7, 561–570. Nolen-Hoeksema, S., Morrow, J., & Fredrickson, B. L. (1993). Response styles and the duration of episodes of depressed mood. Journal of Abnormal Psychology, 102, 20–28. Platt, J. J., & Spivack, G. (1972). Problem-solving thinking of psychiatric patients. Journal of Consulting and Clinical Psychology, 39, 148–151. Platt, J. J., & Spivack, G. (1975). Manual for the Means-Ends Problem-Solving (MEPS): A measure of interpersonal problem-solving skill. Philadelphia: Hahnemann Medical College and Hospital. Rholes, W. S., Michas, L., & Shroff, J. (1989). Action control as a vulnerability factor in dysphoria. Cognitive Therapy and Research, 13, 263–274. Roberts, J. E., Gilboa, E., & Gotlib, I. H. (1998). Ruminative response style and vulnerability to episodes of dysphoria: Gender, neuroticism, and episode duration. Cognitive Therapy and Research, 22, 401–423. Spitzer, R. L., Williams, J. B. W., Gibbon, M., & First, M. B. (1990). SCID user’s guide for the Structured Clinical Interview for DSM-IIIR. Washington, DC: American Psychiatric Press, Inc. Teasdale, J., & Barnard, P. (1993). Affect, cognition and change. Hove, UK: Lawrence Erlbaum Associates Ltd. Teasdale, J. D., Segal, Z. V., & Williams, J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behaviour Research and Therapy, 33, 25–39. Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615–623. Teasdale, J. D., Taylor, R., & Fogarty, S. J. (1980). Effects of induced elation depression on the accessibility of memories of happy and unhappy experiences. Behaviour Research and Therapy, 18, 339–346. Watkins, E., & Baracaia, S. B. (2001). Why do people in dysphoric moods ruminate? Personality and Individual Differences, 30, 723–734.
Rumination and social problem-solving in depression Ed Watkins *, Simona Baracaia Department of Psychology, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK 8 October 2001
Abstract We tested the hypothesis that impaired social problem solving in depression is a consequence of stateoriented rumination, which can be ameliorated by improving awareness of mental processes. 32 currently depressed, 26 recovered depressed, and 26 never depressed participants completed the Means Ends Problem Solving Test while randomly allocated to no questions, state-oriented ruminative questions, (e.g. focusing on why you have a problem) or process-focused questions (e.g. focusing on how you decide to solve a problem). In the no question condition, the currently depressed group was significantly impaired at problem solving compared to the never depressed and recovered depressed groups, which did not differ from each other. As predicted, the process-focused questions significantly improved social problem solving in depressed patients, compared to no questions and state-oriented questions, which did not differ from each other. As predicted, compared to the process-focused questions, the state-oriented questions significantly impaired social problem solving in the recovered depressed group. These results are consistent with recent theories and treatment developments which suggest that increased awareness of mental processes can shift people away from ruminative thinking, thereby, reducing depressive relapse. 2002 Elsevier Science Ltd. All rights reserved. Keywords: Depression; Rumination; Problem solving; Mindfulness
1. Introduction Deficits in social problem solving have been suggested as a core feature of depression (e.g. Beck, 1976; Nezu, 1987), with poor problem solving considered a moderator between the occurrence of stressful life events (e.g. Nezu & Ronan, 1985) and the onset of depression. Depressed patients rate themselves as more ineffective at problem solving (Heppner, Baumgardner, & Jackson, 1985) and show problem solving deficits on objective measures such as the Means Ends * Corresponding author. Tel.: +44-207-848-3226; fax: +44-207-848-5006. E-mail address: [email protected] (E. Watkins).
0005-7967/02/$ - see front matter 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 0 1 ) 0 0 0 9 8 - 5
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Problem Solving Task (MEPS; Platt & Spivack, 1975) compared to controls and anxious patients (Goddard, Dritschel, & Burton, 1996; Marx, Williams, & Claridge, 1992). Furthermore, problemsolving therapy (Nezu, Nezu, & Perri, 1989) produces significant clinical improvements, indicating that problem solving ability influences the prognosis of depression. Recent studies (Lyubomirsky & Nolen-Hoeksema, 1995; Lyubomirsky, Tucker, Caldwell, & Berg, 1999) suggest that rumination may impair problem solving in depression. Nolen-Hoeksema (1991) defined rumination as a response style that involves focusing on and thinking about the causes, consequences and meanings of depressed mood. Research has suggested that people differ in their personal dispositions towards this response style (Nolen-Hoeksema, Morrow, & Fredrickson, 1993), and, furthermore, that the response style can be manipulated by inductions that focus or distract attention from mood state (Nolen-Hoeksema & Morrow, 1993). Dysphoric participants who ruminated on the causes and consequences of their mood were significantly impaired at interpersonal problem solving on the MEPS compared to dysphoric participants who distracted themselves from their mood or non-dysphoric participants in either induction (Lyubomirsky & Nolen-Hoeksema, 1995; Lyubomirsky et al., 1999). Since patients with current and past major depression ruminate significantly more than never-depressed controls, (Roberts, Gilboa, & Gotlib, 1998) rumination may account for the problem solving deficits in depression. Kuhl (1981, 1994) conceptualized rumination as analytical thinking about the causes and consequences of internal states (e.g. mood) and external states (e.g. problems) that had become an end in itself, rather than a means to effective action. In Kuhl’s theory, rather than reflecting a response style, rumination is one aspect of a broader impairment in volitional control called “state orientation”. State orientation is characterized by preoccupation with simulating alternative plans and by the analysis and evaluations of past successes and failures, producing difficulties in initiating new actions. Kuhl also proposed an action orientation, which involves effective volitional control, and is characterized by action planning and effective self-monitoring. People show personal dispositions towards state or action orientation, with State-oriented but not Action-oriented participants more vulnerable to depressive symptoms (Rholes, Michas, & Shroff, 1989). However, the orientations can be manipulated by brief inductions: Explicitly stating hypotheses during a reasoning task removed the performance deficits normally found in State-oriented participants following uncontrollable failure (Kuhl, 1981). By integrating Kuhl’s (1981) account with the findings of Lyubomirsky and colleagues, we hypothesised that impaired social problem solving in depression is a consequence of state-oriented rumination, which can be ameliorated by inducing an action orientation. This account predicts that it is not just the content of thinking (e.g. not thinking about negative mood, i.e. distraction, versus thinking about negative mood, i.e. rumination) that influences problem solving but also the particular style of thinking adopted. Thus, the aim of this study was to test the hypothesis that the thinking style adopted when considering a problem influences the effectiveness of problem solving. To test this hypothesis, this study compared the effects of state-oriented questions, actionoriented questions and no questions during problem solving on the MEPS in currently depressed, recovered depressed and never-depressed groups. In contrast to Lyubomirsky and Nolen-Hoeksema (1995) and Lyubomirsky et al. (1999), who compared the effects of rumination and distraction prior to thinking about an interpersonal problem, this study manipulated participants’ cognitive style when they were thinking about an interpersonal problem. Furthermore, we specifically included a clinically depressed group because Lyubomirsky and colleagues had only used dysph-
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oric students, concluding that “the effects of focusing manipulations on the thinking and problem solving of clinically depressed individuals are largely unknown” (Lyubomirsky et al., 1999, p. 1058). We also included a recovered depressed group to investigate whether problem-solving deficits depend on depressed state or reflect an underlying vulnerability factor. Increased awareness in the here and now is a core aspect of action orientation (Kuhl & Kazen, 1994) and effective action-oriented inductions involve increasing awareness of mental processes (e.g. explicitly stating reasoning hypotheses, Kuhl, 1981). We therefore used questions focusing on the mental process of problem solving as our action orientation condition. Interestingly, the process-focused aspect of action orientation parallels recent theoretical work, which suggests that increasing awareness of thoughts and feelings in the present moment can help treat depression (Teasdale & Barnard, 1993; Teasdale, Segal, & Williams, 1995). Mindfulness-based Cognitive Therapy (MBCT), derived from this theory, uses attentional exercises to increase awareness of thoughts and feelings and significantly reduced depressive relapse over 1 year in recurrent depressed patients, compared to treatment-as-usual (Teasdale et al., 2000). We predicted that currently depressed participants would show general deficits in problem solving compared to never depressed participants, replicating Marx et al. (1992). We predicted that there would be no significant difference in problem solving between state-oriented questions and the no question condition in currently depressed participants, because we expected the currently depressed group to habitually choose a state orientation. Consistent with the hypothesis that increased awareness of mental process improves problem solving, we predicted that the process-focused questions would improve problem solving in the currently depressed group. Consistent with the hypothesis that rumination impairs problem solving, we predicted that the stateoriented questions would impair problem solving compared to the no question and process-focused conditions in the recovered depressed group. Kuhl (1994) proposed that the negative effects of state orientation are only manifest following appropriate setting conditions, such as failure, just as Nolen-Hoeksema (1991) proposed that rumination is only dysfunctional in a dysphoric mood. We therefore predicted that state-oriented rumination would not significantly influence problem solving in the never depressed group. We made no specific predictions about the effect of the process-focused questions in the never depressed group. 2. Method 2.1. Design We used a 3 (Group: currently depressed, recovered depressed, never depressed) ×3 (Condition: no questions, state-oriented questions, process-focused questions) mixed factors design. Participants were randomly allocated to the conditions (no questions, n=27; state-oriented, n=29; process-focused, n=28; cell sizes from 7-11 participants). 2.2. Participants 2.2.1. Currently depressed group (n=32) We recruited 24 women and 8 men (age range 18–65, M=42.3, SD=12.8) meeting criteria for current major depressive disorder (DSM-IIIR, American Psychiatric Association, 1987) on the
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Structured Clinical Interview for DSM-IIIR (SCID; Spitzer, Williams, Gibbon, & First, 1990), from inpatient and outpatient settings. Beck Depression Inventory (BDI; Beck, Rush, Shaw, & Emery, 1979) scores ranged from 16 to 39 (M=25.3, SD=6.5). The mean score on the Ruminative Response Scale (RRS; Nolen-Hoeksema & Morrow, 1991) was 65.0 (SD=11.0). 81.2% were prescribed antidepressants. Co-morbid diagnoses were eating disorder (3.3%), anxiety disorder (28.1%) and alcohol or substance abuse (12.5%). The current depression lasted on average 8.7 months (SD=9.2), mean age of first onset was 21.5 years (SD=8.3) and the number of previous depressions was 6.2 (SD=3.4) (“too many to count” coded as 10). 2.2.2. Recovered depressed group (n=26) We recruited 18 women and 8 men (age range 29–64, M=41.8, SD=9.9), meeting criteria of no current major depression but at least one past major depression on the SCID, and a BDI score of 14 or less (M=7.2, SD=3.8), from a self-help charity for depression. 15.4% were prescribed antidepressants. Other diagnoses were anxiety disorder (11.5%) and past alcohol or drug abuse (11.5%). The mean RRS score was 47.7 (SD=14.5). The age of first onset was 27.6 years (SD=12.9) and the number of previous depressions was 3.1 (SD=2.6). 2.2.3. Never depressed group (n=26) We recruited 16 women and 10 men (age range 20–63, M=36.1, SD=12.2), meeting criteria of no diagnosis of major depression or dysthymia in the present or past on the SCID, and a current BDI score of 14 or less (M=3.8, SD=3.8). None were currently prescribed antidepressants. The mean RRS score was 36.5 (SD=8.2). A Chi-squared test found no significant differences between the Groups in the relative proportions of men and women (p=0.54). Separate 3 (Group) ×3 (Condition) analyses of variance (ANOVAs) found a significant Group effect on BDI scores, F(2,75)=147.0, p⬍0.0001, and on RRS scores, F(2,75)=47.6, p⬍0.0001 (one case missing data). As expected, post hoc Scheffe´ Tests showed that the currently depressed group had significantly higher BDI and RRS scores than the recovered depressed and never depressed groups (p⬍0.001 for all tests). The recovered depressed group was nearly significantly more depressed (p=0.059) and had significantly higher rumination scores than the never depressed group (p⬍0.001). There were no other significant main effects or interactions on BDI or RRS, all F’s ⬍1. 2.3. Materials 2.3.1. Mood measure Participants rated their current mood on an 0–100 scale ranging from 0 I do not feel at all despondent to 100 I feel extremely despondent (Teasdale, Taylor, & Fogarty, 1980). 2.3.2. Beck Depression Inventory The BDI (Beck et al., 1979) is a 21-item self-report measure of symptoms of depression, with good psychometric properties (Beck, Steer, & Garbin, 1988).
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2.3.3. The Ruminative Response Scale (RRS) The RRS is a 22-item self-report measure of how often respondents respond to a sad mood with rumination, with good internal consistency and validity (Nolen-Hoeksema & Morrow, 1991). 2.3.4. Means-Ends Problem-Solving test The MEPS measures the ability to conceptualise step-by-step means (strategies) of achieving a goal. For each MEPS situation, the participant is presented with the beginning and end of a problem. Participant’s answers are scored for the number of discrete steps that are effective in enabling the subject to reach the goal or overcome an obstacle. The MEPS has satisfactory internal consistency (from 0.80 to 0.84) and construct validity (e.g. Platt & Spivack 1972, 1975). This study used a shortened version of the MEPS, consisting of situations 2, 4, 8 and 10, following a precedent adopted by Marx et al. (1992) and Lyubomirsky and Nolen-Hoeksema (1995). These items assess problem solving with respect to different life areas (argument with your partner, difficulty with your boss, a friend avoiding you, making new friends). This study used scenarios worded in the second person, replicating Lyubomirsky and Nolen-Hoeksema (1995) and Lyubomirsky et al. (1999), and asked participants to find the ideal strategy for overcoming the problem situation (Marx et al., 1992). The experimenter read the situations to the participants, who simultaneously followed them on separate index cards. Participant’s answers were noted verbatim. There was no time limit for the task. We measured the time spent to complete each problem. 2.3.5. State-oriented and process-focused conditions In both conditions, participants were instructed to bear in mind seven questions presented on an index card as they tried to think of the best solution to each scenario. The state-oriented questions were naturally occurring questions reported by dysphoric ruminators (Watkins & Baracaia, 2001) that focused on the causes of problems (Kuhl, 1981; Nolen-Hoeksema, 1991). The state-oriented questions were: “What am I doing wrong?”; “What caused this problem?”; “Why can’t I do better?”; “What is the reason behind all this?”; “What’s wrong here?”; “Why can’t I get things right?”; and “How can I understand this?”. The process-focused questions were designed to increase awareness of the mental processes involved in problem solving, and were adapted from questions that improved solution performance on a logical task in non-depressed participants (Berardi-Coletta, Buyer, Dominowski, & Rellinger, 1995). Questions were: “How am I deciding on a way to solve this problem?”; “How am I deciding what to do next?”; “How do I know this is a good thing to do?”; “How am I deciding what might prevent success?”; “What am I thinking about in terms of starting to solve this problem?”; “How do I decide whether my plan needs to be changed?”; and “How do I decide whether that was a useful step towards a solution?”. 2.4. Procedure All of the participants were interviewed using the SCID, and then randomly allocated to one of the three conditions. Participants completed the BDI, RRS, and despondency scale, before the MEPS task was explained to them. In the no question condition, participants completed the MEPS without being presented any extra information. For each problem scenario, participants in the
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state-oriented and process-focused conditions were asked to review the questions on the index card whilst they solved the problem. Following the MEPS, participants rated their despondency again. 2.5. Scoring of the MEPS responses A judge unaware of group or condition scored all responses for number of relevant means and for their effectiveness, using a 7-point Likert-type scale ranging from 1 (not at all effective) to 7 (extremely effective) (e.g. Lyubomirsky & Nolen-Hoeksema, 1995; Marx et al., 1992). A strategy was considered effective if it maximised positive and minimised negative short and longterm consequences (D’Zurilla & Goldfried, 1971). An independent second judge, unaware of group or condition, rated a random 10% selection of all responses, with high interrater reliability (relevant means, r=0.76; effectiveness, r=0.79). 3. Results An alpha level of 0.05 was used for all statistical tests. All analyses were initially performed with sex of participant as a between-subjects factor. There were no significant main effects or interactions with sex of participant; therefore, all analyses reported were conducted by collapsing across sex of participant. 3.1. Group and condition differences in relevant means and effectiveness We analysed the total number of relevant means and the mean effectiveness of problem solving in separate 3 (Group) ×3 (Condition) ANOVAs.1 Figure 1 displays the pattern of relevant means for all groups and conditions (the pattern of results was equivalent for the effectiveness ratings; for economy, only relevant means are displayed). There was a significant main effect of Group, for number of relevant means, F(2,75)=8.3, p⬍0.001 and for effectiveness, F(2,75)=7.3, p⬍0.001. We found a significant main effect of Condition, for number of relevant means, F(2,75)=4.3, p⬍0.02 and for effectiveness, F(2,75)=3.3, p⬍0.05. These main effects were qualified by significant Group × Condition interactions for both the number of relevant means, F(4,75)=3.4, p⬍0.05, and for the ratings of effectiveness, F(4,75)=3.0, p⬍0.03. These interactions were still significant when the analyses were repeated with time to complete problems as a covariate (n=69); relevant means, F(4,59)=2.8, p⬍0.05 and effectiveness, F(4,59)=2.9, p⬍0.03. In order to examine the interactions further, we performed a series of separate ANOVAs within To check that participants had engaged in the appropriate style of thinking during each condition, 3 (Group) ×3 (Condition) ANOVAs were calculated for the number of statements during problem solving that directly reflected state-oriented questions and process-focused questions, respectively. A judge, unaware of group and condition, counted the statements, with high interrater reliability (state-oriented, r=0.962; process-focused, r=0.986), with a second independent judge, who rated a random 20% selection of responses. There were significantly more state-oriented responses (M=3.9, SD=2.8) in the state-oriented condition than in the process-focused (M=0.89, SD=1.03) or no question conditions (M=0.78, SD=0.85), F(2,75)=24.6, p⬍0.001. There were significantly more process-focused responses in the process-oriented condition (M=2.9, SD=2.6) than in the state-oriented (M=0.14, SD=0.58) and no question conditions (M=0.01, SD=0.38), F(2,75)=30.2, p⬍0.001. 1
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Fig. 1. Number of relevant means by group and by condition (error bars represent standard deviations).
each Condition, with Group as the independent variable, and within each Group, with Condition as the independent variable, using relevant means and effectiveness as our dependent variables. Scheffe´ tests were used for the post hoc comparisons in order to reduce the risks of Type 1 errors (Ferguson, 1976). Within the no question condition, there was a significant main effect of Group on the number of relevant means, F(2,24)=7.2, p⬍0.005 and on effectiveness, F(2,24)=6.8, p⬍0.005. Scheffe´ tests indicated that the currently depressed group produced significantly fewer relevant means (p⬍0.01) than the recovered depressed or the never depressed groups (p⬍0.05), which did not significantly differ from each other (p=0.997). The currently depressed group produced significantly less effective solutions than the recovered depressed group (p⬍0.01) and less effective solutions than the never depressed group (p=0.059). Within the state-oriented condition, there was a significant main effect of Group on the number of relevant means, F(2,26)=8.4, p⬍0.001 and on effectiveness, F(2,26)=5.8, p⬍0.01. The currently depressed group produced significantly fewer relevant means (p⬍0.005) and less effective solutions (p⬍0.015) than the never depressed group. The recovered depressed group also produced significantly fewer relevant means (p⬍0.02) and less effective solutions (p⬍0.05) than the never depressed group, whilst not differing from the currently depressed group on number of relevant means (p=0.92) or effectiveness (p=0.96). Within the process-focused condition, there was not a significant main effect of Group on relevant means, F(2,25)=1.1, p=0.34, or on effectiveness, F(2,25)=1.2, p=0.32. Within the never-depressed group, there was not a significant main effect of Condition on relevant means, F(2,23)=0.68, ns, or on effectiveness, F (2,23)=0.35, ns. Within the recovered depressed group, there was a significant main effect of Condition on relevant means, F(2,23)=3.9, p⬍0.05 and on effectiveness, F(2,23)=4.0, p⬍0.05. Compared to the process-focused condition, the state-oriented condition produced fewer relevant means (p⬍0.05) and less effective solutions (p⬍0.05). There was no significant difference in number of
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means produced (p=0.21) or effectiveness (p=0.11) between the state-oriented condition and the no question condition or between the process-focused condition and the no question condition (p=0.57). Within the currently depressed group, there was a significant main effect of Condition on relevant means, F(2,29)=6.31, p⬍0.005 and on effectiveness, F(2,29)=5.53, p⬍0.05. Scheffe´ tests indicated that the process-focused condition had significantly more relevant means than the no question condition (p⬍0.01) and the state-oriented condition (p⬍0.05), which did not differ from each other (p=0.717). Similarly, the process-focused condition produced more effective solutions than the no question condition (p⬍0.02) and approached significance for producing more effective solutions than the state-oriented condition (p=0.089). 3.2. Group and condition differences in dysphoric mood As a test of baseline levels of dysphoric mood, we calculated a 3 (Group) ×3 (Condition) ANOVA with baseline despondency as the dependent variable. There was a main effect of Group, F(2,75)=39.4, p⬍0.001. Post hoc Scheffe´ tests indicate that the currently depressed group was significantly more despondent (M=62.0, SD=19.6) than the recovered depressed group (M=21.2, SD=21.1, p⬍0.001) and the never depressed group (M=19.5, SD=19.7, p⬍0.001) which did not differ from each other (p=0.94). There were no differences in baseline despondency between conditions, F(2,75)=0.20, ns, and the interaction between group and condition was not significant, F(4,75)=0.25, ns. We calculated a 3 (Group) ×3 (Condition) ANOVA with despondency following the MEPS task as the dependent variable, to test whether the variables influenced dysphoric mood. The significant main effect of Group, F(2,74)=34.9, p⬍0.001, was replicated, but there was no other significant main effects or interactions, all Fs ⬍1, i.e., the manipulations did not alter despondent mood. 4. Discussion The aim of this study was to investigate whether the cognitive style adopted when thinking about a problem could influence the outcome of problem solving in depressed people. Specifically, we hypothesised that impaired social problem solving in depression is a consequence of stateoriented rumination, which can be ameliorated by process-focused thinking. We found that manipulating cognitive style during problem solving systematically influenced success at problem solving in a pattern consistent with this hypothesis. First, manipulating orientation towards problems had no effect on the problem solving of the never-depressed group. The never-depressed participants were competent at solving problems in all three conditions. Second, in both the recovered depressed and currently depressed groups, thinking style during problem solving did significantly influence problem-solving outcome. As predicted, the processfocused questions produced significantly more relevant means and more effective solutions than the state-oriented questions in both clinical groups. In the no question condition, the currently depressed group were significantly impaired at problem solving compared to the never depressed group, replicating Marx et al. (1992). Nonetheless, the benefits of the process-focused questions
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were so substantial that in this condition currently depressed patients were as successful at problem solving as the never-depressed group. As predicted, process-focused thinking ameliorated the problem-solving deficit in depression. Conversely, in the state-oriented condition, the recovered depressed patients were as poor at problem solving as currently depressed patients, despite solving problems as well as the never-depressed group in the no question and process-focused conditions. This result suggests that the state-oriented questions impaired problem solving performance in recovered depressed patients, although there was no significant difference between the no question condition and the state-oriented condition in the recovered-depressed group. The current findings provide some evidence that rumination can impair problem solving in clinically relevant groups (Judd, 1997), as well as dysphoric students. Third, the inclusion of the no question condition allowed us to make some inferences about the habitual thinking style adopted by default for problem solving in the clinical groups. The lack of a significant difference in problem solving between the no question condition and the stateoriented condition in the currently depressed group is consistent with our hypothesis that depressed patients habitually choose a state orientation if left to their own devices. The pattern of results for the recovered depressed group is consistent with their habitual style being intermediate between the currently depressed and never depressed groups. These hypotheses are consistent with self-reported patterns of rumination (Nolen-Hoeksema, 2000; Roberts, Gilboa, & Gotlib, 1998): depressed patients report significantly more rumination than recovered depressed patients, who in turn, report significantly more rumination than never depressed people. Previous studies of rumination (e.g. Nolen-Hoeksema & Morrow, 1993) found elevated levels of depressed mood following the rumination induction compared to the distraction induction in dysphoric participants. In contrast, we did not find elevated levels of despondent mood in the state-oriented rumination condition compared to the other conditions for any group. The differential effects of the state-oriented and process-focused questions seem to be unrelated to changes in mood. As noted earlier, this study examined the effects of thinking style during problem solving, rather than the effects of distraction or rumination about dysphoric mood prior to problem solving. This change in methodology might account for the difference in mood effects: NolenHoeksema (1991) posited that rumination about dysphoric mood was necessary for exacerbation of negative mood, whilst in this study, participants ruminated about arbitrary interpersonal problems. Nonetheless, the process-oriented condition might be expected to improve mood because of its beneficial effect on problem solving. Clearly, for real-life problems, improved problem solving would be expected to improve mood. However, the MEPS problems were arbitrary and imaginary such that solving them should not impact on participants’ lives and, thus, would not be expected to improve mood. The pattern of results suggests that depressed patients adopt a style of thinking that impairs their ability to solve interpersonal problems. Furthermore, these findings suggest that one possible mechanism of relapse in recovered depressed patients is state-oriented responses to a stressful life event leading to impaired social problem solving and further escalation of the stressful situation (Nezu & Ronan, 1985). More pertinently, it was possible to shift currently depressed patients to a more effective problem solving style, at least over the brief time-course of this study, by using process-focused questions. The limitations of this study, of course, were that we could not ascertain how long an induced action orientation would persist, nor do we know whether the manipulations would influence solution generation to personally relevant, real-life problems.
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Given the construct validity of the MEPS (Platt & Spivack, 1975), sustaining this shift in thinking style in a more enduring way would, presumably, help to maintain effective interpersonal problem solving in both current and recovered depressed patients, with ramifications for treatment and relapse prevention (e.g. Nezu et al., 1989). The ability of current psychological treatments to produce an enduring shift into a processfocused orientation is not known. Although neither cognitive therapy (Beck, 1976) nor problem solving therapy (Nezu et al., 1989) explicitly focus on encouraging a process-focused orientation, aspects of these therapies (e.g. thought monitoring, problem definition) may implicitly do so. As discussed earlier, MBCT does explicitly encourage increased awareness of thoughts in the present moment through the use of daily attentional exercises. Thus, encouraging a process-focused orientation rather than a state-orientation in recovered depressed patients, and, thereby, facilitating effective interpersonal problem solving may be one potential mechanism by which MBCT reduces depressive relapse. Future research could usefully examine whether process-focused thinking plays a role in effective therapy and investigate how we can systematically induce an enduring process orientation in patients. In conclusion, the current results replicate the finding that people with current major depression are impaired at social problem solving and are consistent with the hypothesis that state-oriented rumination determines this deficit. The impaired problem solving found for recovered depressed people in the state-oriented condition suggests that rumination can impair problem solving in a clinical sample and suggests a potential mechanism of depressive relapse. A process-focused condition improved problem solving in currently depressed patients, consistent with the hypothesis that inducing action-oriented responses improves problem solving. Acknowledgements This study was supported by a grant to Edward Watkins from the Lesley Ann Smith fund, Psychiatry Research Trust. References American Psychiatric Association, (1987). Diagnostic and Statistical Manual of Mental Disorders. (3rd ed revised). Washington, DC: American Psychiatric Association. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford Press. Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twentyfive years of evaluation. Clinical Psychology Review, 8, 77–100. Berardi-Coletta, B., Buyer, L. S., Dominowski, R. L., & Rellinger, E. R. (1995). Metacognition and problem solving: A process-oriented approach. Journal of Experimental Psychology: Learning, Memory and Cognition, 21, 205–223. D’Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification. Journal of Abnormal Psychology, 78, 107–126. Ferguson, G. A. (1976). Statistical analysis in psychology and education. Tokyo: McGraw-Hill. Goddard, L., Dritschel, B., & Burton, A. (1996). Role of autobiographical memory in social problem solving and depression. Journal of Abnormal Psychology, 105, 609–616. Heppner, P. P., Baumgardner, A., & Jackson, J. (1985). Problem-solving self-appraisal, depression, and attributional style: Are they related? Cognitive Therapy and Research, 9, 105–113.
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