Countering discounting (the positive) in depression
We have all had at least one depressed client who – even when they had an experience that defied their pessimistic assumptions – refused to be swayed by the evidence. A doomsday prophet surrounded by blue skies and laughter on the day of the forecast apocalypse. The tendency for depressed people to change their appraisals of experiences that would otherwise be evidence against their negative beliefs has been known by everyone else for years as “discounting”, “disqualifying” or “minimising” but has recently been re-labelled cognitive immunization by Rief and colleagues. However, as they’re doing important work trying to understand how to undo this self-defeating behaviour, let’s not begrudge them their patented phrase. But I couldn’t bring myself to make it the title.
Kube and colleagues (2019) gave 113 people with major depressive disorder a standardized performance test, consisting of 3 blocks of trials, after each of which they would receive feedback. The task was designed so that it would be difficult for participants to tell how well they were doing (they had to empathise with an actor describing a range of different situations and try to predict which emotions the actor experienced). Participants were then given standardized feedback (regardless of the actual similarity in their ratings to those of the actor) such that they were led to expect that they were in the top 15% of participants who had taken the test.
Participants were randomized to one of 4 groups:
INFORMATION: After feedback, these participants received information that people who perform well on the test they had just taken have more professional satisfaction, earn higher incomes and are more satisfied with the quality of their social relationships.
RECALL: After feedback, these participants were instructed to remember how well they performed on this “difficult” test and to indicate on a numeric scale where they had performed compared to other participants.
ATTENTION: Before taking each block of the test they were asked to indicate on a rating scale what would constitute a good result for them, personally. They were then told to carefully focus on how they actually performed.
CONTROL: Received no additional instructions before taking the test or after receiving feedback.
The three experimental conditions were all intended to interfere with discounting: the information was intended to increase the credibility and importance of the feedback (experience); the recall condition was intended to better “update” the representation of their expectation in memory; the attention condition was meant to focus the client’s attention on how different the actual experience was from their expectations (making it more difficult to “explain away”). The instructions in each condition were carefully phrased to disguise the manipulation and avoid demand characteristics. The primary outcome of interest was participants’ generalized performance expectations, measured as only the Germans could phrase it: “I will be successful in working on unknown tasks in general” rated from 1 “I totally disagree” to 7 “I totally agree” (Kube et al., 2018).
Participants in all conditions held more optimistic expectations after receiving feedback than before attempting the task. However, there was a greater increase in optimistic expectations in the Information condition than the control condition, and in the Information condition compared to the Recall condition. The Attention condition produced changes in between Information and Recall that were not statistically significant from either. The Information group also reported significantly lower cognitive immunization scores than each other group, measured as the amount by which participants question the credibility and relevance of the task they’ve just performed.
Although extrapolating from the controlled laboratory setting to real-world clients is easier said than done, this study has some credibility to violate pessimistic assumptions about working with depressed clients. The mean BDI scores of these participants was in the moderately depressed range and the participants were inpatients of a German “psychosomatic” hospital.
Take home: Clinical Implications
Routinely assess for the tendency to discount information that contradicts pessimistic and negative expectations among depressed clients.
Educate these clients that the tendency to discount information is common in depressed people, is a cognitive handicap that keeps depression going, but is controllable and changeable
Before engaging in behavioural experiments, ask clients about what sources of information they find most credible, and what kind of new information and experiences would be most valuable to them to have. Ensure the client sees the relationship between the experiment you’re planning and gaining these valuable experiences. Ensure the client can explain their linkage back to you. Record these understandings in the way the client would most like to refer to them (i.e., writing, photo, audio, video).
Spend time after successful behavioural experiments reviewing the record you made of how valuable expectation-disconfirming evidence would be.
There is a lot of research to support that the expectations of the kind of people willing to participate in research studies are modifiable by the presentation of research findings. If your client is similar, you may be able to bolster new more optimistic beliefs by providing relevant research findings supporting them. If the client does not care about research, you could see if there are other “authorities” (e.g., peer opinions – especially if they have recovered from depression, famous heroes’ endorsements, user-defined indicators) the client would find more credible sources of feedback about their beliefs.
Go to https://www.sciencedirect.com/science/article/abs/pii/S0165032718332737 for the original article.