135

SPECIAL SERIES CURRENT PERSPECTIVES ON IMPLICIT COGNITIVE

IN CLINICAL DISORDERS: IMPLICATIONS A S S E S S M E N T A N D INTERVENTION

PROCESSING FOR

Introduction

T i b o r Palfa i , Boston Universi ty Er ic E W a g n e r , Florida In t e rna t iona l University

This special series presents six different articles addressing the roles of implicit cognition and automatic processing in the treatment of psychopatholo~. Although each article addresses a very, different clinical population, the articles all offer concrete examples of how the study of implicit cognition may enhance real-world clinical assessment and treatment. In addition, they explain how cognitive psycholo~ methods may be utilized to avoid response biases, identify dysfunctional cognitive processes, and specify the nature of men- tal representations in various disorders. The ultimate aim of this special series is to make a compelling case for translating research on implicit cognition into instruments and intervention techniques with clinical utility.

T HE PAST DECADE has seen a dramat ic increase in re- search on implici t cognitive processing in clinical

psychology. Investigators have uti l ized findings from this work to greatly advance theory regard ing the nature of dysfunctional cognitive schema and processes that char- acterize various clinical d isorders (e.g., Baxter & Hinson, 2001; Beck & Clark, 1997; Gemar, Segal, Sagrati, & Ken- nedy, 2001). Despite these advances, appl icat ions of this research to clinical pract ice remain largely undeveloped. The objective of this special series of articles is to br ing toge ther investigators who have s tudied implici t cogni- tive processing across a variety of psychological disorders, and to have them discuss clinical implications of their research. Our ul t imate goal is to advance clinical assess- men t and t rea tment across clinical disorders by incorpo- rat ing knowledge f rom recent research on implici t cogni- tive processing.

Our use of the term "implicit cognitive processing" in- eludes implici t cogni t ion and automat ic cognitive pro- cesses. While there are differences among researchers in how each of these constructs is def ined, investigators gen- erally have ut i l ized the d i cho tomies of impl ic i t -expl ic i t cogni t ion and automat ic-contro l led cognitive processes to distinguish cognitive p h e n o m e n a that involve certain functions of consciousness from those that do not. For example , implici t cogni t ion has been def ined as traces of past exper ience that inf luence responses even when this inf luence is not known or is inaccurately ident i f ied by the individual (Greenwald & Banaji, 1995). A large body of

Cognitive and Behavioral Practice I I , 1 3 5 - 1 3 8 , 2004 1077-7229/04/135-13851.00/0 Copyright © 2004 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

research has shown that individuals may exhibit j u d g m e n t or behavior that is inf luenced by informat ion in memory, even though they are not aware of this inf luence or are no t del iberate ly a t tempt ing to utilize this informat ion. In- deed , these influences may be at odds with informat ion that is consciously accessible at any given time. Impl ic i t cogni t ion is noneonscious in the sense that the individual does no t del iberate ly utilize this informat ion or is not aware of how this specific informat ion in memory influ- ences pe r fo rmance , j udgmen t , or emot iona l state (Stacy, Ames, & Leigh, 2004). For example , Wilson, Lindsey, and Sehooler (2000) refer to implici t at t i tudes as evaluations that individuals have about objects or events that are acti- vated automatical ly and inf luence responses (e.g., behav- ior toward an out -group member ) , without the individual be ing aware that he or she is express ing an evaluat ion toward that object.

Since implici t cogni t ion is no t accessible to conscious int rospect ion, it must be s tudied with measures that do not rely on verbal r epor t about the p h e n o m e n o n u n d e r study. Thus, the pr imary me thodo logy for studying im- plicit cogni t ion involves indi rect or implici t measures. In memory research, implici t memory is revealed by perfor- mance on tasks such as word f ragment comple t ion (e.g., i_pl c_t) in which individuals are asked to identify a se- ries of words that include those previously presented , even though they are not asked to del iberate ly retrieve informat ion from memory. Such tests are re fer red to as indi rec t tests of memory because evidence for memory of a previous exper ience is ga ined indirect ly th rough per- fo rmance on the task ra ther than direct in t rospect ion about past events.

Similarly, implici t at t i tudes are assessed with the use of procedures that do not require that the individual become

136 Patfai & Wagner

aware of his or her evaluation. For instance, the Implicit Association Test (Greenwald, McGhee, & Schwartz, 1998), a measure used by many authors in this series (Fr iedman & V~qfisman, 2004; Teachman & Woody, 2004: Vartanian, Poli~ T, & Herman , 2004), assesses implici t att i tudes by using a task in which part ic ipants simply categorize exem- plars according to certain dimensions. In contrast to the use of a se l f - repor t scale assessing evaluat ions as con- sciously e x p e r i e n c e d , impl ic i t a t t i tudes are revealed indirect ly th rough pat terns of response times.

Investigators often have descr ibed the opera t ion of implici t cogni t ion in terms of automat ic processes (Fried- man & Whisman, 2004: Stacy et al., 2004). The terms "au- tomaticity" and "automatic processes" frequently are used in psychopathology research to denote characteristic ways of using informat ion from internal (e.g., memot T) and external (environmental) sources. Many investigators have adop ted the distinction between automatic and control led processes in o rde r to separate informat ion processes that inw)lve consciousness from those that do not (Shiffrin & Schneider, 1977). Cont ro l led processes are associated with the f imctions of consciousness inc luding del ibera- tion, in tent ional i t T, effortful l imited capacity processing, and exper ient ia l awareness. Automat ic processes, on the o ther hand, have been def ined as those that opera te with- out in tent ional control , are resource independen t , may be conduc ted in parallel , and occur without awareness. Al though this cluster of antomat ic at tr ibutes appears to characterize certain forms of skill-learning and attentional processes, many cognitive opera t ions are character ized by e lements of both cont ro l led and automat ic processes (Bargh, 1996; McNally, 1995; Wegner & Bargh, 1998). Moreover, studies of automat ic cognitive processes have shown that features of automatici ty do not always cluster togedmr (Bargh. 1996). For example, the intrusive thoughts characterist ic of obsessive-colnpulsive d i sorder are clearly exper ienced in awareness and consnme cognitive capaciD~ yet a r e i n w l l u n t a D" (McNally. 1995). Similarly, automatic trait inferences may occur without awareness yet still re- quire cognitive resources and d i sappear when cognitive capacity is occup ied with a paral le l task (Bargh, 1996). As the articles in this special series demonst ra te , the crea- t ion of novel assessment and t rea tment techniques may be opt imal ly advanced by using a more di f ferent ia ted view of au tomat ic i ty in clinical d isorders (see also Mc- Nally, 1995).

Why Study Implicit Cognition and Automatic Processes?

Much of the research descr ibed in this special series has been inf luenced by the informat ion processing ap- proach to studying psychopathology: Ingram and Kendall (1986) have character ized this app roach as one that fo-

cuses on the person as an informat ion processing system that selects, transforms, and utilizes informat ion from in- ternal and envi ronmenta l sources. For the clinical psy- chologist who works within this framework, a key task is to unders tand how disorders are caused and ma in ta ined by dysfunctions in the way that informat ion is r epresen ted and utilized. Many cognitive models of psychopathology" adop t the view that indMduals e i ther do not have access to, or are not aware oI, the opera t ion of the processes that maintain their clinical disorders. Cognitive sche- mata, for example , inf luence p e r c e p t i o n , j u d g m e n t , and behavior without subjective awareness (Beck & Clark, 1997; McNally, 1995). Similarly, the cognitive dysfunc- tions that character ize certain disorders are fundamen- tally cognitive processing deficits that occur outside of awareness (Newman, 1998; Wallace & Newman, 2004).

Ingram and Kendall (1986) make the distinction be- tween cognitive products (i.e., information available to awareness, such as thoughts, feelings, and decisions), cog- nitive opera t ions (i.e., processes by which informat ion is t ransformed and utilized, such as retrieval and atten- t ion), and cognitive schema (i.e., the conten t of informa- tion that is s tored in memoD: and the way that this infor- mat ion is s t ructured) . Al though self-report of cognitive products may proxdde valuable dam about cognitive schema and operat ions, certain characterist ics of menta l pro- cesses and representations cannot be studied in this manner (Nisbett & Wilson, 1977: Segal, 1988). Indirect measures permi t assessment of these e lements and consequent ly allow for more accurate study of key theoretical constructs (Segal, 1988). Moreover. methods that rely on se l l ' repor t lnay be more snsceptible to self-presentational or response biases, especially when assessing p h e n o m e n a that may be conflictual for the indMdua l (e.g., urges to dr ink for a person who has been manda ted to alcohol t rea tment) . While not excluding the value of self-report data, the in- format ion processing approach also utilizes a n u m b e r of methods that allow investigators to study characterist ics of these cognitive schema and cognitive opera t ions that are not amenable to study using self-report methods .

Clinical Implications of Research on Implicit Cognition and Automatic Processing

The investigators of this special series clarify why the study of implici t cognit ion and automat ic processing is so central to the under s t and ing of psychopathology. In ad- dition, they explain how cognitive psychology methods may be utilized to avoid response biases, identify, dysfunc- t ional cognitive processes, and specig/ t i le nature of men- tal representat ions in various disorders. However, the main contr ibut ions of these articles are their discussions of how indirect tests and the study of implici t cogni t ion may enhance real-world clinical assessment and t reatment .

Introductory Comments 137

The t r emendous potent ia l for improved assessment is out l ined by a number of authors in this issue (Fr iedman & Whisman, 2004; Stacy et al., 2004; Teachman & Woody, 2004; Vartanian et al., 2004). Stacy et al. review an impres- sive body of research that has been conduc ted on the use of implici t associations to assess behaviorally relevant ele- ments of heal th-re la ted representat ions . For Stacy et al., a part icularly impor t an t e l emen t of automatici ty is sponta- neous retrieval. They descr ibe a n u m b e r of association tasks that are used to assess involuntary retrieval in re- sponse to heal th-relevant cues and outcomes. Using a relapse prevent ion perspective, they suggest that these indi rect measures allow one to assess behavioral ly rele- vant cognit ions that are automatical ly activated by high- risk cues. This research expands assessment techniques that rely on self-reported triggers and allows for the as- sessment of associations between cues and responses in memory. Not only have these associative measures shown to have significant predict ive value for clinically relevant ou tcomes , Stacy et al. have shown how they may be adap ted to assess the accessibility of coping skills, identify specific high-risk triggers following intervention, and iden- tify cl inically mean ingfn l r ep re sen ta t i ons that are no t verbally based.

The value of indi rec t measures for assessing dysfunc- t ional cognitive schema and processes is fur ther devel- oped by Teachman and Woody (2004) and by Vartanian et al. (2004). These authors descr ibe the implicat ions of their research with the Implici t Association Test (IAT; Greenwald et al., 1998). Teachman and Woody describe the potent ia l value of such measures as a means of devel- op ing ideographic cognitive profiles that represen t the con ten t and nature of associations between cues and fear responses. This measure may help assess intervent ion tar- gets of which the individual may not be fully aware to bet- ter focus t reatment . In addi t ion, the IAT may be used to assess progress in t r e a t m e n t and discern vulnerabi l i ty to relapse. However, as Vartanian et al. suggest, implici t associations may be inf luenced by a n u m b e r of variables (e.g., cultural norms) that may no t be indicative of psy- chopathology. Al though this task has significant clinical potential , there must be a concer ted effort to demonstra te the unique predictive value of per formance on such tasks. Vartanian et al. suggest the value of in tegra t ing indirect and self-report measures to bet ter unde r s t and issues re- lated to denial of illness and self-presentational concerns, as well as making decisions about opt imal intervent ion approaches .

For many of the authors in this issue, under s t and ing implici t cogni t ion and automat ic processes allows us to design more explici t strategies to target processing char- acteristics of which the individual may be unaware. How- ever, this app roach also lends itself to the deve lopmen t of more effective t r ea tment strategies. F r iedman and Whis-

man (2004) suggest that indi rec t tests provide a way to identify automat ic processing deficits that may be amelio- ra ted by he lp ing the pa t ien t utilize conscious, de l ibera te processing strategies. They suggest that goals of interven- tion techniques in cognitive therapy may be to try to in- crease control over automat ic processes and, where this is not possible, to minimize the degree to which these pro- cesses inf luence mood, thought , and behavior. Th rough pa t ien t educat ion, thought moni tor ing, and mindfulness techniques, individuals may be able to become more aware of automat ic dysfunctional thought pat terns and break the automat ic association between cues and responses. One of the key t rea tment goals is to help pat ients identify these automat ic processing strategies and replace them with del ibera te ones. They suggest that identif icat ion of these implicit processes within the therapeut ic interact ion may be particularly impor tant for breaking dysfunctional cognit ive-interpersonal cycles.

Wallace and Newman (2004) also suggest that auto- matic processing deficits characteristic of psychopathy may be addressed th rough strategic interventions. Adop t ing a self-regulation framework, they suggest that psychopathy is fundamenta l ly a processing deficit in which automat ic a t tent ional processes that are secondary to the individ- ual 's goal pursui t are impaired . They suggest that this in- ability to utilize secondary information leads to an inability to regulate p repo ten t response tendencies. They present a n u m b e r of cognitive and behavioral techniques that may be employed to help individuals compensa te for an in- efficient use of secondary informat ion inc luding pa t ien t educat ion, mon i to r ing strategies, cond i t ion ing strategies to facilitate pausing and de l ibera t ion in goal pursuit , and t raining in the evaluation of response options. These and o the r strategies are des igned to remedia te self-regulation deficits in specific automat ic process (i.e., cognitive oper- ations) ra ther than specifically a t tending to characteristics of dysfunctional schema.

Finally, Palfai (2004) has also focused on processing characteristics related to self-control in p rob lem drinking. Adop t ing a self-regulatory framework, Palfai emphasizes the role of automat ic processes in effective self-regulation of alcohol use. This work suggests that automat ic and cont ro l led processes may independen t ly inf luence the success of self-regulatory strategies. Moreover, it appears that certain cont ro l led coping strategies may inadver- tently interfere with self-control because of their influence on automat ic processing. Palfai suggests that a bet ter un- ders tand ing of the in teract ion between automat ic and cont ro l led processes may improve se l f -management ap- proaches for problem drinking, and presents ways in which interventions may be designed to simultaneously influence both types of processing.

In sum, the articles in this special series emphasize the impor tance of studying implici t cogni t ion and de l inea te

138 Palfai & Wagner

a n u m b e r o f p o t e n t i a l r e s e a r c h d i r e c t i o n s to d e v e l o p c l in i -

cal a s s e s s m e n t a n d t r e a t m e n t t e c h n i q u e s . A l t h o u g h i m p l i c i t

a n d a u t o m a t i c p r o c e s s e s h a v e b e e n c e n t r a l to c o g n i t i v e -

b e h a v i o r a l t h e o r y f b r m a n y yea r s , t h e u s e o f c l i n i ca l m e t h -

o d s to a s s e s s t h e s e e l e m e n k s i n t r e a t i n g p s y c h o p a t h o l o g y

h a s n o t b e e n fu l ly r e a l i z e d . H o p e f u l l y , t h e a r t i c l e s in t h i s

s e r i e s will h e l p m a k e t h e c a s e f o r t r a n s l a t i n g r e s e a r c h o n

i m p l i c i t c o g n i t i o n i n t o i n s t r u m e n t s a n d i n t e r v e n t i o n t e c h -

n i q u e s t h a t m a y b e w i d e l y u s e d in c l i n i c a l practice.

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Baxter, B. W., & Hinson, R. E. (2001). Is smoking automatic? Demands of smoking behavior on attentional resources.Journal of Abnormal I3~chology', 110, 59-66.

Beck, A. T., & Clark, D. A. (1997). An information processing model of anxie~< Automatic and strategic processes. Behavior Research and Therapy', 35, 49-48.

Friedman, M. A., & Whisman, M. A. (2004). Implicit cognition and the maintenance and treatment of nlajor depression. Cognitive and Behavioral Practiee, 11, 168-177.

Gemar, M. C., Segal, Z. V., Sagrati, S., & Kenned> S..l. (2001). Mood- induced changes on the hnplicit Association Test in recovered depressed patients. Journal of Abnormal Psychology, 11 O, 282-289.

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Teachman, B. A., & Woody, S. R. (2004). Staying tuned to research in implicit cognition: Relevance for clinical practice with anxiety dis- orders. Cognitive and Behavioral Practice, 11, 149-159.

Vartanian, L. R., Poli~ T, J., & Herman, C. (2004). Implicit cognitions and eating disorders: Their application in research and treat- ment. Cognitive and Behavioral Practice, 11, 160-167.

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The guest editor tbr this special series was Tibor PaltM. The journal action editor for this special series was Eric Wagner.

Address correspondence to Tibor Palfai, Department of Psychology, 648 Beacon St., Boston Universit); Boston, MA 02215; e-mail: palfai@ bu.edn.

Received: April 21, 2002 Aceepted: August 26, 2002