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Effectively Treating Pathological Self-Criticism in Depressed & Dysthymic Clients
Effectively Treating Pathological Self-Criticism in Depressed and Dysthymic Clients

Section 19
Vulnerability’s Ties to Self-Criticism and Depression

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Conventional vulnerability model
In this section, I examine some of the limitations associated with the conventional vulnerability model to understanding the proximal effects of vulnerability factors on both mood and behaviour. Typically, vulnerability and mood are assessed at baseline, mood is re-assessed at follow-up, and the number and type of events occurring between baseline and follow-up assessments are categorized and aggregated. Some studies also include assessment of the vulnerability factors at follow-up. Individuals scoring high on a specific vulnerability (e.g. self-worth) at baseline who have also experienced a number of intervening events congruent with the vulnerability (e.g. demotion or a poor performance review) should be more depressed at follow-up than individuals who either do not possess the baseline vulnerability or who did not experience vulnerability-congruent intervening events. Support for this model is used to infer that observed intervening events activated or caused the depressed mood in vulnerable individuals.

Results from a number of studies are consistent with the view suggesting that the independent effects of events on mood may be nominal (Alloy & Clements, 1998; Dykman & Johll, 1998; Johnson, 1995; Monroe, Bromet, Connell, & Steiner, 1986; Suh, Diener, & Fujita, 1996). Indeed, several studies have shown that only a small amount of variance in mood scores at follow-up can be attributed to the occurrence of events, after accounting for variance in baseline mood scores. Monroe et al. (1986) showed that baseline depression and marital conflict predicted 37% of the variance in depression at their 1-year follow-up, and the interaction term for social support and events only explained an additional 1% of the variance. Similarly, Suh et al. (1996) found that 37% of the variance in negative mood assessed at 2-year follow-up was attributable to negative mood at baseline, but that negative events did not account for follow-up mood scores after controlling for baseline mood scores.

However, results of these studies need to be reconciled with long-term studies that have found support for the role of life events in increasing the risk for onset of a depressive episode (e.g. Bebbington et al., 1988; Brown, Bilfulco, & Harris, 1987; Brown, Harris, & Hepworth, 1995; Brown & Moran, 1997; Kendler et al., 1995; Lewinsohn, Allen, Seeley, & Gotlib, 1999). Differences between those studies examining the manner in which the severity of depressed mood scores change and covary over time and other studies examining the role of events in increasing the risk of onset of a depressive disorder are important and potentially complex. Indeed, differences may reflect: (a) the manner in which depression is assessed (severity vs episodes); (b) the interval length between testing times; and (c) the manner in which events are assessed (checklist vs interview).

Proximal effects on mood
Understanding the proximal effects of vulnerability factors on mood and behaviour requires a fundamentally different methodology. Studies examining negative events, mood, and vulnerability factors have generally used measures of depressive severity, such as the Center for Epidemiological Studies – Depression scale (CES-D; Radloff, 1977) or the Beck Depression Inventory (BDI; Beck, Steer, & Garbin, 1998), to assess mood as depicted in the model. These measures of depressed mood typically assess a broad spectrum of depressive symptomatology, and often assess symptoms or difficulties associated with depression, which are not central to a diagnosis of depression. As a result, high scores on these measures may be achieved in a number of ways but do not necessarily reflect a disturbance in symptoms that are considered central to a mood disorder (Coyne, 1994; Depue & Monroe, 1986). Very little is known about the specific mood states to which vulnerability factors are related.

Moreover, the manner in which mood is typically assessed emphasizes the severity of mood states rather than the duration of mood disturbances or fluctuations. Individuals completing the CES-D are asked to report "how often [they] felt or behaved this way, during the past week." Individuals completing the BDI identify "the one statement in each group [of symptoms] that best describes the way [they] have been feeling during the past two weeks, including today." Strictly speaking, neither measure was designed to assess the duration of symptoms, although one of the key features characteristic of a depressive disorder is its duration. Critics have argued that high levels of distress, no matter how severe, do not warrant the same clinical attention as depressive disorders (Coyne, 1994). High levels of distress are typically short-lived and are infrequently related to a formal diagnosis of depression (Coyne, 1994; Coyne & Schwenk, 1997).

Conceptualizing and classifying events
A third challenge associated with the model is to understand the nature of the events that activate depressive vulnerabilities. Traditionally, events have been designated as belonging to one of two mutually exclusive domains on the basis of their descriptive features. Failure events typically include being fired from a job, whereas rejection events generally include losing a romantic partner or withdrawal of support (c.f. Segal et al., 1992; Zuroff & Mongrain, 1987). Distinguishing events on the basis of their descriptive features has been useful, albeit arbitrary. However, it does not explain what it is about such events that activate vulnerabilities. Other theorists have proposed classifying situations on the basis of the different personal needs a situation fulfills or threatens rather than on the basis of their descriptive features (Brown & Harris, 1978; Rotter, 1954). Yet, even though life events and hassles can be conceptualized in many ways, surprisingly little work has been applied to the conceptualization of events believed to have an etiological role in the onset of depression.

Ethological models of human behavior have emphasized the importance of the attachment system which governs the manner in which individuals manage separations from individuals to whom they feel emotionally close (Bowlby, 1969), as well as the social rank system governing how individuals maintain and acquire social status within a dominance hierarchy (Gilbert, 1992; Price, 1967; Price, Sloman, Gardner, Gilbert, & Rohde, 1994). Such a view acknowledges that ostensibly different events may address similar needs and that single events may fulfill different needs. Accordingly, losing a romantic partner may threaten the self-worth needs of self-critical individuals just as being fired from a job could threaten the attachment needs of dependent individuals.

Proximal effects on behaviour
Understanding events in terms of the various needs that may be threatened within a social rank or attachment framework offers a number of important avenues for understanding the manner in which vulnerability factors may moderate interpersonal behavior, affect the quality of interpersonal interactions, and contribute to long-term mood difficulties. From a social rank perspective, how individuals respond to events, such as outperforming or disagreeing with a partner, can affect status and rank and the extent to which they can garner support from allies and respect from competitors, within a social hierarchy. However, given the importance of maintaining relationships and protecting self-worth to dependent and self-critical individuals, it is likely that vulnerability factors such as dependency and self-criticism will moderate the manner in which such events are experienced and the way in which individuals respond.

In a series of experimental studies, we have shown that outperforming a close friend or romantic partner can precipitate appeasement behavior towards partners in dependent individuals (Israeli & Santor, 2001; Santor et al., 2001; Santor & Zuroff, 1997; 1998), whereas being outperformed by a close friend or romantic partner can produce retaliatory behavior in self-critical individuals (Israeli & Santor, 2001; Santor et al., 2001; Santor & Zuroff, 1997; 1998). This is consistent with the model in which competition in interpersonal contexts can be threatening for individuals high on dependency as well as those high on self-criticism (albeit in different ways) and illustrates that manner in which both social rank and attachment systems can intertwine. These studies have shown that dependency and self-criticism are associated with an array of cognitive, affective, behavioural, and motivational differences. Dependent individuals tend to adopt the responses of friends they outperformed (Santor & Zuroff, 1997), relinquish control over shared resources to less competent friends (Santor & Zuroff, 1998), praise friends even when friends disagreed (Santor & Zuroff, 1997), and minimize disagreement with disagreeing friends (Santor & Zuroff, 1997; 1998). With romantic partners, dependency predicted an increase in the frequency of suggestions and agreeable comments following unfavorable feedback (Santor et al., 2001) and an increase in appeasements following hostile attacks (Israeli & Santor, 2001). In contrast, self-critical women contested threats to status (Santor & Zuroff, 1997; 1998), withheld praise from friends who challenged them (Santor & Zuroff, 1997), did not minimize disagreement with disagreeing friends (Santor & Zuroff, 1997; 1998) and actively exerted control over shared resources (Santor & Zuroff, 1998), even at the expense of a close friend, regardless of the status or behavior of the close friend. With romantic partners, self-criticism predicted a decrease in the frequencies of suggestions and agreeable comments and an increase in the frequency of blaming (Santor et al., 2001) and in unprovoked attacks on others (Israeli & Santor, 2001). These results are consistent with the view promoted by Segal and Ingram (1995) in which it is argued that an activating event is required.

- Santor, Darcy A.; Proximal Effects of Dependency and Self-Criticism: Conceptual and Methodological Challenges for Depressive Vulnerability Research; Cognitive Behaviour Therapy; 2003; Vol. 32; Issue 2.

Personal Reflection Exercise #5
The preceding section contained information regarding how vulnerability relates to depression and self-criticism.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Andrews, L. A., Hayes, A. M., Abel, A., & Kuyken, W. (2020). Sudden gains and patterns of symptom change in cognitive–behavioral therapy for treatment-resistant depression. Journal of Consulting and Clinical Psychology, 88(2), 106–118.

Birk, J. L., Kronish, I. M., Moise, N., Falzon, L., Yoon, S., & Davidson, K. W. (2019). Depression and multimorbidity: Considering temporal characteristics of the associations between depression and multiple chronic diseases. Health Psychology, 38(9), 802–811.

Dunkley, D. M., Starrs, C. J., Gouveia, L., & Moroz, M. (2020). Self-critical perfectionism and lower daily perceived control predict depressive and anxious symptoms over four years. Journal of Counseling Psychology. Advance online publication.

Online Continuing Education QUESTION 19
How does out-performing a close friend or romantic partner affect dependent individuals? Record the letter of the correct answer the CEU Test.

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