The relationship between co-rumination and depression, anxiety and social anxiety

in a UK community sample.

Nicola Griffiths

Submitted for the Degree of

Doctor of Psychology(Clinical Psychology)

School of PsychologyFaculty of Health and Medical Sciences

University of SurreyGuildford, SurreyUnited KingdomSeptember 2017

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Statement of Originality

This thesis and the work to which it refers are the results of my own efforts. Any ideas, data, images, or text resulting from the work of others (whether published or unpublished) are fully identified as such within the work and attributed to their originator in the text. This thesis has not been submitted in whole or in part for any other academic degree or professional qualification.

Name: Nicola Griffiths

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Overview of Portfolio

Co-rumination is a form of repetitive problem discussion within dyadic relationships. It has conceptual overlaps with rumination and has been found to have adaptive and maladaptive facets, which result in it being positively correlated with both negative affect and friendship quality. This thesis aimed to further explore the relationship between co-rumination and psychological distress such as depression and anxiety within a variety of dyadic confidant types. Part one of this portfolio presents a review of the current literature regarding the relationship between co-rumination and psychological distress. The findings of the review suggested that there were current gaps in the research field. It was concluded that the field of co-rumination required further longitudinal research, further research on the impact of different confidant types and further research into the relationship between co-rumination and anxiety including different subtypes of anxiety. Part two presents an empirical paper that used a two-wave study to explore the relationship between co-rumination and three types of negative affect (depression, generalized anxiety and social anxiety). Additionally stratifying results by confidant type. The findings suggested that co-rumination is related to negative affects with modest effect sizes. However findings suggests that the process by which this effect takes place may not be purely due to ruminative process as was previously hypothesised. Additionally findings suggested that the impact of co-rumination differs according to the confidant with whom the discussions take place. Part three documents experience gathered from placements conducted during doctoral training and part four is a list of assignments completed.

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Table of Contents

Acknowledgements ……………………………………………………………….. 6

Research Part 1 – Literature reviewThe Relationship between Co-Rumination and Psychological Distress…………. 7Abstract…………………………………………………………………………… 8Introduction ………………………………………………………………………. 9

Aim ……………………………………………………………...………. 13Method………………………………………………………………………….... 13

Data Sources and Search Terms……………………………………….… 13Inclusion and Exclusion Criteria……………………….……...………… 14Data Screening…………………………………………..……………….. 15Data Extraction ………………………………………………………..… 16Analysis of Study Quality…………………………………………………. 16

Results…………………………………………………………………………….. 21Study Descriptives……………………………………………………....… 22Depression……………………………………………………………....… 23Anxiety ………………………………………………………………..…... 24Internalising and Externalising Problems…………………………....…… 24Deliberate Self Harm (DSH) ……………………………………………… 24Quality of Articles Reviewed………………………………………….…… 24

Discussion…………………………………………………………………………. 26Conclusions ……………………………………………………..………… 32

References…………………………………………………………………………. 33

Research Part 2 – Empirical PaperThe relationship between co-rumination and depression, anxiety and social anxiety in a UK community sample. ………………………………………………………… 38Abstract……………………………………………………………….…………… 39Introduction…………………………………………………………………………41

Study Aims…………………………………………………………………. 47Method……………………………………………………………………………... 48

Design……………………………………………………………………… 48Participants ……………………………………………………………….. 49Measures……………………………………………………………..……. 50Ethics…………………………………………………………………..……52Procedure …………………………………………………………………..52Analysis…………………………………………………………………..….53

Results………………………………………………………………………………54Sample Characteristics…………………………………………………….. 54Study Measures – Descriptive Statistics…………………………………… 55Correlational analysis of full sample……………………………………… 57Hierarchical multiple regression………………………………………….. 60

Discussion…………………………………………………………………………. 62Summary of findings……………………………………………………….. 62Methodological critique…………………………………………………… 66Theoretical and clinical implications……………………………………….68

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Future research …………………………………………………………… 71Conclusions…………………………………………………………………73

References…………………………………………………………………………. 75Appendices………………………………………………………………………….81

Appendix A: Copy of online questionnaire from Qualtrics…………………...82Appendix B: Ethical approval letter…………………………………… ……….88Appendix C: Tests of statistical assumptions…………………………………90Appendix D: Graphs of participant drop out……………………………….95

Part 3- Summary of Clinical Experience……………………………………………96

Part 4 – Table of Assessments Completed during Training………………………98

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Acknowledgements

I would like to thank my research supervisors Dr Laura Simonds and Dr Jason Spendelow who have supported me throughout my research. I would like to thank

Andrew Barnes who supported me in my use of Qualtrics and Dr Alison Yeung who advised me regarding research writing skills. Last but not least I would also like

to thank my friends and family who have supported me throughout my course.

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The Relationship between Co-Rumination and Psychological Distress

 

Word Count: 4621

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Abstract

Background: Co-rumination entails extensive discussion of and speculation about

problems, usually between two people, with a focus on negative feelings. Whilst co-

rumination is theorised to have positive effects on friendship quality that might be

protective against emotional distress, it has been proposed that co-rumination might

have negative effects on emotional wellbeing given its conceptual overlap with

rumination, a process that impacts negatively on wellbeing. Consequently, there has

been speculation regarding the relationship between co-rumination and psychological

distress. The current paper presents a review of the literature regarding the

relationship between co-rumination and psychological distress. Methodology: Web

of Science, PsychInfo and Pubmed were searched using terms relating to co-

rumination and psychological distress. Sixteen papers were included in the review.

Emotional wellbeing was operationalized in these studies as depression, anxiety,

internalising problems, externalising problems, and deliberate self-harm (DSH).

Findings: Evidence regarding the relationship between co-rumination and emotional

distress was mixed. Whilst some studies found evidence for a significant relationship

between co-rumination and depression with a small effect size, others reported no

relationship. Three studies observed significant relationships between co-rumination

and anxiety with small to medium effect sizes. There was evidence of significant

relationships between co-rumination and internalising problems with a small effect

size, but no evidence of a relationships co-rumination and externalising problems.

Conclusions: The review suggests there may be a relationship between co-rumination

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and psychological distress and that the type of dyadic relationship may impact upon

the effect. Implications of these findings and the quality of the data are discussed.

Introduction

The concept of co-rumination was developed by Rose (2002) following a seemingly

paradoxical observation that young girls report more internalizing problems than

young boys despite having closer friendships, which should, theoretically, be a

protective factor against emotional difficulties. She proposed that this observation

might be due to the way in which problems were being discussed within close

friendships. Co-rumination has subsequently been developed to describe this process

and is defined as the discussion of personal problems to an excessive extent within a

dyadic relationship. It is characterised by mutual encouragement of problem talk in

which the problems are discussed and speculated about frequently and repeatedly

with a focus on negative feelings. Rose conceptualised that co-rumination might be

related to enhanced friendship quality, but that it might also relate to emotional

problems due to conceptual overlap with rumination. The phenomenon was primarily

observed and conceptualised within friendship dyads in childhood and adolescence

(Rose 2002). However other dyadic relationships such as romantic partner, room-

mate and parental dyads have since been studied (Calmes & Robert 2008; Grimbos,

Granic & Pepler, 2013) and the field has broadened to focus on co-rumination within

adult relationships.

Research has found a relationship between co-rumination and internalising problems

such as depression (Rose et al 2007, Serwick, 2011) and anxiety (Rose et al 2007;

Schwartz-Mette & Rose 2012). Co-rumination is conceptually similar to rumination

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in regard to the repetitive and speculative nature of problem focus. Since rumination

has also been linked to psychological distress (Morrison & O’Conner, 2005; Nolen-

Hoeksema, Wisco & Lyubomirsky 2008), Rose hypothesised that co-rumination may

be related to internalising problems through similar processes (Rose 2002). The

repetitive negative focus upon a problem, which is seen within both rumination and

co-rumination, is hypothesised to trap people in to an unhelpful information

processing response which leads to the development of cognitive biases by which

negative thoughts and beliefs are reinforced (Mellings &Alden 2000). However

research by Balsamo et al (2015) introduced an alternate mechanism by which co-

rumination may be linked to affect. They speculated that the process of co-

rumination might lead to the activation of maladaptive schemas leading to the

observed affect.

However co-rumination has been found to also exhibit some positive trade offs,

which may be linked to reduced psychological distress. Co-rumination has

conceptual cross overs with social support seeking, which is theorised to be link to

improved mental health and wellbeing (Shumaker, & Brownell, 1984). In children

and adolescents having a close friendship is thought to protect against emotional

difficulties (Bukowski, Hoza, & Boivin, 1994). Additionally self-disclosure as part

of a friendship has been found to have beneficial outcomes for both the individual

and the relationship (Sprecher & Hendrick, 2004). Given this information it is

hypothesised that co-rumination may have a beneficial effect through these

processes. Co-rumination has been found to have some positive outcomes in terms of

friendship quality (Rose, Carison & Waller, 2007), decreased loneliness (Mercer &

DeRosier, 2010) and increased understanding leading to improved coping (Dam,

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Roelofs & Muris, 2014). Thus it would appear that co-rumination has both adaptive

and maladaptive facets.

As the body of research into the concept of co-rumination has grown, factors that

may influence the relationship between co-rumination and psychological distress,

and the possible processes involved in this have started to be explored. As

aforementioned, co-rumination has been found to take place within a variety of

dyads. Calmes and Roberts (2008), for example, found that whilst friend based co-

rumination was related to both depression and anxiety, parent based co-rumination

was only related to anxiety, and room-mate based co-rumination was not found to

have a relationship with either anxiety or depression. This indicates that co-

rumination impact may be influenced by relationship type. Given that co-rumination

is proposed to combine positive and negative effects, it is possible that the positive

effects observed are more protective in some relationships than others or that the

negative effects have greater impact in certain relationships.

Co-rumination, if associated with psychological problems, could offer a valuable

way of further understanding the process by which psychological distress is

exacerbated and maintained. Rose (2007) highlights the potential benefit this

understanding could offer within adolescent education, suggesting that it could be

helpful in understanding ways in which friendships may be helpful or unhelpful, and

challenge the assumption that close friendships are always supportive. More broadly,

research indicates that co-rumination occurs through a number of means such as face

to face within friendships (Rose 2002) and between parents and children (Grimbos,

Granic & Pepler, 2013). It takes place over the phone (Murdock, Gorman &Robbins,

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2015) and via social media (Devila et al 2012). As a result co-rumination could be

present day to day for a large number of individuals and, therefore, understanding its

potential impact is important.

Horwitz and Wakefield (2007) stated that distress is part of human existence and

whilst, in some cases, diagnostic criteria are used to categorise psychological

distress, caution should be taken regarding pathologising normal psychological

phenomena. Distress is multifaceted, incorporating a continuum of psychological

functioning and impact on wellbeing. The concept of co-rumination emerged from an

aim to explain the observation that young girls have more confiding relationships

than boys but also report more anxiety and depression. As such, the concept and the

field developed from the study of non-clinical school-based samples. Therefore, the

study of co-rumination is situated within a dimensional approach to understanding

distress and focuses on understanding ways to prevent and reduce psychological

distress.

Due to this context, research has focussed on the broader continuum of internalising

problems such as anxiety and depression, instead of focussing on discrete categorical

‘disorders’. Therefore when reviewing the present literature the umbrella term of

“psychological distress” was chosen to encompass a range of presentations. Krueger

(1999) noted that distress might exhibit via externalising or internalising processes.

When distress is externalised the focus or impact is directed externally, towards

others for example aggression or antisocial behaviour. In contrast, with internalised

distress the impact and focus is aimed inwardly, towards the self; as seen in

depression or anxiety.

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For the purposes of this review the term “psychological distress” has been chosen to

include both internalising and externalising symptoms, in order to explore the current

understanding about the relationship of co-rumination with each of these. The term

will include sub-clinical levels of distress such as low mood and anxiety as well as

research into co-rumination and psychiatric disorders. The term will however

exclude problems that are purely physical or social in nature or causation.

Aim

The primary aim of the current review is to assess the evidence regarding the

relationship between co-rumination and psychological distress. A secondary aim is

to assess the quality of the current literature and, in doing so, to consider in which

areas further research may be required in order to advance understanding of the

potential psychological outcomes of co-rumination.

Method

Data Sources and Search Terms

Data for this review was firstly gathered through computer searches of online

databases. The databases used were Web of Science, PsychInfo and Pubmed. These

databases were searched between February and May 20161. Hand-searching then

took place using the references and citations from relevant articles alongside

searching relevant journals; such as those that had published the existing articles.

1 A meta-analysis by Spendelow, Simonds and Avery (2016) has not been included in this literature review as it had not been published at the time of searching.

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Search terms were chosen with reference to those used in previous research on co-

rumination and also with reference to related conceptual areas with the aim of

capturing a range of articles related to co-rumination. The list of terms used can be

found in Table 1.

Table 1. Search terms Term 1 (separated by OR)

Term2(separated by OR)

Co-ruminat*Coruminat*Co-problem solving Co-reflectingCo-broodingMullingFailure anticipation Problem talk

AND Psych* distress Psych* disorder*Psych* problems Internalising problemsExternalising problemsMental healthWellbeingMoodCoping Distress Psyc* functioningPsych* illness Daily functioningAdaptive functioning Depress*AnxietyDisord*

Inclusion and Exclusion Criteria

The review included peer-reviewed journal articles reporting studies that used

quantitative methods and analysis to estimate statistically the relationship between

co-rumination and psychological distress (which was broadly constructed to include

clinical and sub-clinical levels of distress including internalising and externalising

problems). No restrictions were placed on age or gender of participants. Studies

where included if they used validated measures of co-rumination and psychological

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distress either in their original form, or adapted or translated versions. However only

English language articles were included.

Figure 1. Study selection process flow chart

Data Screening

A PRISMA flow diagram describing the screening process can be seen in Figure 1.

Following removal of duplicates, first level screening focussed on title and abstract.

Second level screening involved assessing the full text article in accordance with the

inclusion and exclusion criteria. Following these two levels of screening, sixteen

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articles were selected. All were quantitative studies that estimated the relationship

between co-rumination and psychological problems as defined above.

Data Extraction

The following information was extracted from each study: participant sample size

and characteristics, information regarding the measures used and analysis conducted,

and the effect size and statistical significance of relationships between co-rumination

and psychological problems. When extracting data only that pertaining to the

questions posed in this review was extracted. Where further information was present

in the articles, for example friendship quality, this data was not extracted.

Analysis of Study Quality

Quality of the studies used was assessed using the standard quality assessment

criteria for evaluating primary research papers devised by Kmet, Lee and Cook

(2004). The quantitative study checklist was used to numerically score ten aspects of

study quality. Each criterion was scored out of two (where yes = 2, partial = 1 and no

= 0) with the total score for each study being 20. This assessment tool was chosen to

make the process of quality assessment more systematic and quantifiable in order to

compare studies and note areas of weakness within the literature.

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Table 1. Study sample size and descriptive characteristics

Study N Age Range Mean Age (sd) % Female Country Population % White

Balsamo et al 2015 461 18–36 23.93 (6.90) 55% Italy University 100%

Bastin et al 2015 368 9 -15.00 11.72 (1.10) 63% Netherlands School -

Calmes & Roberts 2008 345 18-45 19.7 (3.1) 63% USA University 56%

Criss 2016 206 10–18 13.37 (2.32) 51% USA - 29.6%

Davidson 2014 362 - 19.9 (2.8) 67.1% USA University 84.3%

Hankin 2010 350 11–17 14.5 (1.40) 57% USA School 53%

Latina, Giannotta & Rabaglietti 2015 709 13-18 15.53 (1.03) 46.8% Italy School -

Moreira 2016 307 - 18.39 (0.36) 65% USA University 40%

Nicolai 2013 111 - 16.40 (1.33) 72% USA School 75 %

Rose 2002 608 8-16 - 52% USA School 87%

Rose et al 2007 813 8-16 - 51% USA School 86%

Schwartz-Mette & Rose 2012 548 8-16 - 53% USA School 85.5%

Starr 2015 51 - - 75% USA University 35%

Starr & Davilla 2009 83 11-15 13.45 (0.68) 100% USA School 89%

Stone, Uhrlass & Gibb 2010 81 9-14 11.3 (1.41) 58% USA Community 79%

White & Shih 2012 279 18-25 - 67% USA University 89.2%

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Table 2. Overview of study methods and relevant findings

Study Design Co-rumination Measure

Distress measure

Analysis method

Results

Balsamo et al 2015

Cross sectional

CRQ TDI Correlational Positive statistically significant correlation between co-rumination and depression with small effect size (r=.104, p< .05). CRQ Chronbach’s alpha was .96.

Bastin et al 2015

Longitudinal

CRQ CDI Correlational Positive statistically significant correlation between co-rumination and depression at T1 with small effect size (r=.12, p< .05). No significant correlations between co-rumination and Depression at T2, T3 & T4 ( r=0.08,

r=0.09 & r=0.11respectively). CRQ Chronbach’s alpha was .95Calmes & Roberts

2008

Cross sectional

CRQ (16 Items)

BDI, BAI Correlational Positive statistically significant correlations between friend-based co-rumination and depression (r = .23, p<.01) and Anxiety (r=.21, p<.01) with small effect sizes.; Positive statistically significant correlations between parent-

based co-rumination and anxiety (r = .15, p<.01) with small effect size. No significant correlations between parent-based co-rumination & depression (r = .01). No significant correlation between roommate co-rumination

& depression or anxiety (r=.00, r=.05 respectively). No significant correlation between romantic partner co-rumination and depression or anxiety (r=.01 & r=.03 respectively). CRQ Chronbach’s alphas were .94-.98

Criss 2016 Cross sectional

CRQ (15 items)

MFQ Correlational Positive statistically significant correlation between co-rumination and depression with small effect size (r= .19, p<.05). CRQ Chronbach’s alpha was .96.

Davidson 2014

Cross sectional

CRQ CES-D, PSWQ, IDI

Correlational No significant correlation between co-rumination and depression (r= .10). Positive statistically significant correlation between co-rumination and worry with small effect size (r= .23, p<.01).

CRQ Chronbach’s alpha was .97Hankin 2010

Longitudinal

CRQ (9 Items)

MASQ, SDQ, CDI,

ALEQ

Correlational &

Hierarchical Linear

Modelling

Positive statistically significant correlations between co-rumination at baseline significantly associated with general internalizing symptoms 3/4 time points (rs = .02 to .15, r average=.12 with p<.05 at Times 2, 3,and 4 but

not Time 1), with anxious arousal at all four time points (rs = .10 to .17, r average = .13), with externalizing problems at two out of four time points (rs = .00 to –.16, r average = .07 with p<.05 at Times 1 and 3 but not

Times 2 or 4), with anhedonic depressive symptoms at one time point (at Time 2, rs = .02 to .13, r average = .06) but not with general depressive symptoms bivariately at any time point (rs = .04 to .06, r average =.05). CRQ

Chronbach’s alphas were .89-.91Latina,

Giannotta &

Rabaglietti 2015

Longitudinal

CRQ (9items)

Prinstein Non-

Suicidal Self-injury

Scale

Correlational Positive statistically significant correlation between co-rumination and depression with small effect size (r=.18, p<.05). No significant zero order correlation between co-rumination & DSH, when controlling for T1 DSH negative statistically significant correlation between co-rumination and DSH with small effect size (r= -.07,

p<.05). CRQ Chronbach’s alpha was .92

Moreira 2016

Longitudinal

CRQ CES-D, IPA, RSEI

Correlational No significant correlation between co-rumination and depression at T1 or T2 (r=.08, r=.04 respectively). CRQ Chronbach’s alpha was .98.

Nicolai 2013

Longitudinal

CRQ (3 items)

CDI, Correlational&

Hierarchical Linear

Of 30 correlations examined, only 5 showed a statistically significant relationship between co-rumination (CR) and depression (D). 3 of these had a small effect size, 2 had a medium effect size (CR T1 and D at T1 r= -.16, T2

r= -.14, T3 r=-.05, T5 = -.29, p<.01 T6 r=-.14, T7 -.37, p<.01; CR T2 and D at T2 r= -.08, T3 r=.23, p<.05, T4 r=.16, T5 r= .20, T6 r=-.09, T7 r=.07, T8 r=-.03; CR T3 and D at T3 r=.21, T4 r=-.05, T5 r=.20, T6 r= -.09, T7

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Modelling r=-.07, T8 r=-.03; CR T4 and D at T4 r=.18, T5 r= .16, T6 r=.20, T7 r=.21, T8 r=.24, p<.05; CR T5 and D at T5 r=.12, T6 r=.07, T7 r=-.03, T8 r=.10; CR T6 and D at T6 r=.04, T7 r=.07, T8 r= .11,; CR T7 and D at T7 r=.13,

T8 r=.33, p<.001, CR T8 and D at T8 r=.10). CRQ Chronbach’s alphas were .87-.94.Rose 2002 Cross

sectionalCRQ CDI, CMAS Correlational Positive statistically significant correlation between co-rumination and internalising problems with small effect

size (r=.20, p<.001). CRQ Chronbach’s alpha was .96.

Rose et al 2007

Longitudinal

CRQ CDI, CMAS Correlational Positive statistically significant correlations between co-rumination and depression with small effect sizes at T1 and T2 (r=.13, p<.001, r=.20, p<.001 respectively). Positive statistically significant correlations between co-

rumination and anxiety with medium effect sizes at T1 and T2 ( r=.33, p<.0001; r=.42, p<.0001). CRQ Chronbach’s alpha was .97.

Schwartz-Mette &

Rose 2012

Longitudinal

CRQ CDI, CMAS Correlational Positive statistically significant correlations between co-rumination and depression with small effect sizes at T1 and T2 (r=.11, p<.01, r=.12, p<.01 respectively).; Positive statistically significant correlations between co-

rumination and anxiety with small to medium effect sizes at T1 and T2 (r=.35, p<.001, r=.29, p<.001 respectively). CRQ Chronbach’s alpha was .97.

Starr 2015 Cross sectional

CRQ MINI, Diary kept of mood

Correlational No significant correlation between co-rumination and depression or depressed mood (r=.11, r=.05 respectively). CRQ Chronbach’s alpha was .95.

Starr & Davilla 2009

Cross sectional

CRQ CES-D Correlational Positive statistically significant correlation between co-rumination and depression with small effect size (r=.25, p<.05). CRQ Chronbach’s alpha was .95

Stone, Uhrlass & Gibb 2010

Cross sectional

CRQ CDI Odds Ratio  Higher levels of co-rumination were related to increased risk for lifetime depression, Wald= 4.32, p = .04, odds ratio (OR) = 2.07 (95% confidence interval [CI]: 1.04, 4.12). CRQ Chronbach’s alpha was.97

White & Shih 2012

Cross sectional

CRQ BDI, POMS-SF

Correlational Positive statistically significant correlation between co-rumination and depression with small effect size (r=.13, p<.05). No significant correlation between co-rumination and and Depressive symptoms (r=.06). CRQ

Chronbach’s alpha was .97.

Note: CRQ = Co-Rumination Questionnaire (Rose 2002); TDI = Teate Depression Inventory; CDI= Children’s Depression Inventory (Kavacs 2003); BDI= Beck Depression Inventory – II (Beck et al 1996); BAI = Beck Anxiety Inventory (Beck et al 1988); MFQ= Mood and Feelings Questionnaire (Arnold, Costello, Messer, & Pickles, 1995); MASQ = Mood and Anxiety Symptom Questionnaire (Watson et al., 1995); SDQ Strengths and Difficulties Questionnaire (Goodman 2001); ALEQ = Adolescent Life Events Questionnaire (Hankin & Abramson, 2002); Prinstein non-suicidal self-injury scale (Prinstein et al 2008); CES-D = Centre for Epidemiological Studies Depression Scale (Radolff, 1991); IPA Inventory of Peer Attachment (Armesden & Greenberg, 1987); RSEI Rosenberg Self-Esteem Inventory (Rosenberg 1965); CMAS = Childrens Manifest Anxiety Scale (Reynolds & Richmond 1985); MINI = Mini – International Neuropsychiatric Interview (Sheehan ey al 1998); POMS-SF = Profile of Mood States, Short Form (Shacham 1983)

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Table 3. Analysis of Study QualityStudy 1 2 3 4 8 9 10 11 13 14 Total by Study (max=20)

Balsamo et al 2015 2 2 1 2 2 2 2 2 2 2 19Bastin et al 2015 2 2 1 1 2 2 2 1 2 2 17

Calmes & Roberts 2008 2 2 1 2 2 2 2 2 2 2 19

Criss 2016 2 2 1 2 2 1 2 2 2 2 18

Davidson 2014 2 2 1 2 2 2 1 2 2 2 18

Hankin 2010 2 2 1 2 2 2 2 2 2 2 19

Latina, Giannotta & Rabaglietti 2015 2 2 1 1 2 2 2 2 1 2 17

Moreira 2016 2 2 1 2 2 2 2 2 2 2 19

Nicolai 2013 1 2 1 2 2 1 2 2 2 1 16

Rose 2002 2 2 2 1 2 2 2 2 2 2 19

Rose et al 2007 2 2 1 1 2 2 2 1 2 2 17

Schwartz-Mette & Rose 2012 2 2 1 1 2 2 2 2 2 2 18

Starr 2015 2 2 1 1 2 1 2 2 2 1 16

Starr & Davilla 2009 2 2 1 2 2 1 2 2 2 2 18

Stone, Uhrlass & Gibb 2010 2 2 1 2 2 1 1 2 2 2 17

White & Shih 2012 2 2 2 1 2 2 2 2 2 2 19

Total by Criteria (max=32) 31 32 18 25 32 27 30 30 31 30  

1.Question/objective sufficiently described?; 2. Study design evident and appropriate?; 3. Method of subject selection or source of information/input variables described and appropriate?; 4. Subject characteristics sufficiently described?; 8. Outcome and (if applicable) exposure measure(s) well defined and robust to

measurement/misclassification bias? Means of assessment reported?; 9. Sample size appropriate?; 10. Analytic methods described/justified and appropriate? 11. Some estimate of variance is reported for the main results?; 13. Results reported in sufficient detail? 14. Conclusions supported by the results? Questions 5,6,7&12

not scored as not applicable for the studies used. Scores given were: yes=2, partial=1 & no=0.

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Results

Study Descriptives

Table 1 summarises the sample size and characteristics of the studies reviewed. The

sixteen studies were published between 2002 and 2016. Nine of the studies were

cross sectional and the remaining seven were longitudinal. Eleven studies used the

original version of the Co-rumination Questionnaire (CRQ; Rose 2002) and five

studies used a shortened version. Hankin (2010) and Latina Giannotta & Rabaglietti

(2015) used 9 items taken from the CRQ, Nicolai (2013) used 3 items, Criss (2016)

used 15 items and Calmes and Roberts (2008) used 16 items. All studies reported

good internal consistency despite shortening the original measure. A variety of

measures were used to assess psychological problems (see Table 2).

Most studies recruited samples of young children and adolescents, this perhaps

reflects the fact that Rose developed the concept of co-rumination in the context of

child and adolescent wellbeing. The age of the participants studied ranged from 6-

45 but for all but two studies the mean age was below the age of twenty.

Additionally, when considering the gender proportions within these studies, females

were over-represented within most samples. Thirteen of the studies took place in

America, two in Italy and one in Belgium, and in all but one study, the majority of

participants were Caucasian.

All studies reported an effect size r with the exception of one (Stone, Urless and

Gibb 2010) who reported an odds ratio with confidence interval. A summary of the

statistical findings is shown in Table 2. Effect sizes have been categorised using the

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Cohen (1988) guildelines ( r >10 = small, r >30 = medium, r >50 = large). Findings

are synthesised below and have been categorised by the nature of psychological

distress measured within the study.

Depression

Fifteen of the sixteen studies reviewed explored the relationship between co-

rumination and depression specifically. Eight of these studies were cross-sectional.

Of these studies seven found a statistically significant positive relationship with a

small effect size, two found a non-statistically significant positive relationship with a

small effect size, and one found no relationship with an effect size less than .10.

Calmes & Roberts (2008) explored the relationship between co-rumination and

depression in different dyadic relationships and found that the effect size varied by

type of dyad. In friendship dyads there was a statistically significant positive

relationship between co-rumination and depression with a small effect size. However

in parent-child dyads, romantic dyads and roommate dyads no relationship was

observed. Stone, Uhrlass & Gibb (2010) analysed their findings using odds ratios

rather than correlation. They found that high co-rumination in mother-child dyads

may be related to an increased risk of lifetime depression.

Seven studies explored the relationship between co-rumination and depression using

longitudinal study designs. Three of these studies found consistent statistically

significant positive correlations with small effect sizes between co-rumination and

depression across the time points studied. Two studies found no relationship with an

effect size less than .10. The remaining two studies observed that the relationship

between co-rumination and depression did not remain consistent over time. Bastin et

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al (2015) assessed co-rumination and depression at four time points and found

positive correlations with small effect sizes at time points one and four; however

only the relationship at time point one was statistically significant and no relationship

was observed at time points two and three. Nicolai, Laney and Mezulis (2013)

measured both co-rumination and depression at eight time points and correlated the

findings. Of the 30 correlations reported, only five showed a statistically significant

relationship, but the nature of the relationship was inconsistent. Three correlations

were small (two showing a positive relationship, one negative), and two were

moderate (one exhibiting a positive relationship, one negative).  

Anxiety

Five of the sixteen studies reviewed estimated the relationship between co-

rumination and anxiety. Of these studies two were cross sectional. Davidson (2015)

found a statistically significant positive relationship between co-rumination and

worry with a small effect size. Calmes & Roberts (2008) estimated the relationship

between co-rumination and anxiety in different dyadic relationships and, as for

depression, found that the effect size varied by type of dyad. In friendship dyads and

parent-child dyads there was a statistically significant relationship between co-

rumination and anxiety with a small effect size. This contrasts with the findings for

depression where Calmes and Roberts did not find a significant relationship in

parent-child dyads. As for depression, in romantic dyads and roommate dyads no

relationship was observed between co-rumination and anxiety.

Three of the studies explored the relationship between co-rumination and anxiety

using longitudinal study designs. These studies found consistent correlation results

23

across the time points studied with one (Hankin 2010) finding a statistically

significant positive relationship with a small effect size and two (Rose 2007;

Schwartz-Mette & Rose 2012) finding statistically significant positive relationships

with a small to medium effect sizes.

Internalising and Externalising Problems

Two studies (Hankin 2010; Rose 2002) estimated the relationship between co-

rumination and internalising problems. Internalising problems in each study were

measured by combining measures of anxiety and depression. Both studies found a

significant positive correlation between co-rumination and internalising problems

with a small effect size. Hankin (2010) found no relationship between co-rumination

and externalising problems.

Deliberate Self Harm (DSH)

Latina, Giannotta & Rabaglietti (2015) was the only study to look at DSH as a form

of psychological distress. The study focussed on 13 to 18 year olds in Italy and

measured co-rumination, DSH, depressive symptoms and ease of communication

with parents using questionnaires at two time points, six months apart. The study did

not find evidence of a relationship between co-rumination and DSH at zero order

correlations but when controlling for T1 DSH a significant negative relationship with

a small effect size was found.

Quality of Articles Reviewed

The quality of articles was assessed using ‘The standard quality assessment criteria

for evaluating primary research papers’ by Kmet, Lee and Cook (2004). Papers are

24

scored numerically against ten criteria to give a score of which the maximum

achievable is twenty. Within this quality assessment tool fourteen criteria are listed,

however four of these were not used because they were criteria to assess

experimental designs and were therefore not applicable. Table 3 outlines the scores

obtained by each paper. The papers reviewed scored within the range of 16-19,

which indicates that the quality of the papers reviewed was generally high. No papers

fell below the cut off score at which Kmet, Lee and Cook (2004) suggested papers

should be excluded due to quality.

Areas of strength across the papers selected were the clarity with which the research

question and study design was described, as well as the detail in which results were

reported. The main area of weakness noted when assessing the quality of the studies

included was the sampling strategies employed. Many of the studies recruited

participants from specific locations such as schools in one state or area. This means

that the samples used within the studies reviewed were unlikely to be representative

of the general population, which may impact upon external validity. In addition

participants in the studies reviewed would have been self selected, which may

introduce another element of potential bias; for example, people with a pre-existing

interest in the area may be more likely to apply and therefore the sample may not

represent the general population. These issues are considered further in the

Discussion section. A second area of weakness within the studies reviewed was the

reporting of participant characteristics. Several studies did not include statistics

regarding age and some did not report characteristics regarding the diversity of the

participants. This makes it difficult to comment about how representative these

samples were of the general population.

25

Discussion

The evidence gathered regarding the relationship between co-rumination and

psychological problems is mixed. There is some evidence of a modest positive

relationship between co-rumination and psychological problems such as depression,

anxiety and internalising problems. However in the case of depression not all studies

supported this. Seven of the studies reviewed found a significant relationship whilst

four did not. The lack of consistency in findings could be due to a variety of factors

such as methodological issues or moderator variables, such as type of dyad. These

factors are discussed below.

All studies included in the review explored internalising problems; only one study

additionally explored externalising problems, but found no relationship. Whilst there

is not currently enough data to draw solid conclusions from these findings, this

would be an interesting line of research to pursue. It would be of interest to explore

whether co-rumination is only related to internalising problems or whether there is

also a relationship between co-rumination and externalising problems. According to

Rose’s (2002) theory, the maladaptive components of co-rumination may, by their

nature, be more likely to lead to internalising problems due to aspects of negative

self-focus. Additionally ruminative cognitive and behavioural patterns have been

found to be more present in internalising problems then in externalising problems

(Garnefski, Kraaij & Van Etten, 2005); therefore it may not be surprising that as yet

no link has been found between co-rumination and externalising problems.

26

Initial findings regarding DSH provide a possible interesting difference between the

effects of rumination and co-rumination. Whilst rumination has been found to

increase vulnerability to DSH (Hoff & Muehlenkamp, 2009), the findings of Latina

et al (2015) are contrary to this, indicating that co-rumination may decrease the

likelihood of DSH. The authors speculate that this is due to the support seeking

aspects of co-rumination, which has been found to be a protective factor in DSH

(Christoffersen et al, 2015). Thus, it could be that for this specific element of

psychological distress, the social support inherent within the concept of co-

rumination outweighs the impact of the ruminative nature of the discussions.

However, since there is currently only one piece of research into the relationship

between co-rumination and DSH, further work may be required to confirm the

findings and broaden understanding of the processes involved.

Calmes & Roberts (2008) noted that the relationship between co-rumination and

anxiety and depression varies between types of dyadic relationship. This finding

could explain some of the variability in findings and have an implication for

generalisability. Since the majority of studies examined same-sex friendship dyads,

several of the findings may only be applicable when considering co-rumination

within this type of relationship. Findings may not apply to other dyadic relationships,

such as romantic dyads or child-parent dyads. Further research into the variability

between dyads would be required to clarify whether the findings regarding these

differences are replicable, however, as the current evidence is only from one study.

These results also open a new avenue of research considering whether there are

factors within the interpersonal relationship which impact upon how co-rumination

relates to psychological distress. For example Ponce et al (2010) noted that males

27

who only had peer confidants were more likely to develop depression than those who

had familial confidants with or without peer support. The authors concluded that

there might be something different about the support that a family member provides

which may protect against depression.

Stone, Uhrlass & Gibbs (2010) explored the impact of mother-child co-rumination

upon child affect, which at present appears to be an understudied area that may

warrant further future research. The study explored the lifetime risk of depression

related to co-rumination and therefore has potential utility in terms of preventing

development of depression. However a limitation of the study is the cross-sectional

nature of the design. This makes it difficult to examine causality, as it might be that

depressed children draw their parents into ruminative discussions.

The concept of parent-child co-rumination may offer a new perspective upon the

impact that interactions with parents may have on a child’s mental health. It could be

hypothesised that since parental confiding and influence is thought to change over

time (Smith, Cowie & Blades 2003), parent-child co-rumination could also

potentially impact differently across a lifespan. For example research indicates that

influence and, consequently, confiding behaviours moves from being located with

parents at a young age and then moves to peers during adolescence. Therefore it

could be hypothesised that co-ruminative behaviours in parents may have more

impact in early childhood but that peer-based co-rumination has the greater impact in

adolescence. Currently this has not been studied within co-rumination literature, so

further research would need to be undertaken to explore whether this is the case or

not. It could be argued that the co-rumination and depression relationship observed in

28

these dyads may additionally be impacted upon other factors such as attachment style

(Dykas & Cassidy 2011). Since attachment style has been linked to social support

seeking (Florian, Mikulincer & Bucholtz 2010) it may influence the way children

engage in co-ruminative interactions both with parents and peers.

Effect sizes observed within the studies reviewed were primarily in the small effect

size range (Pallant 2007). This suggests that, relative to other factors, co-rumination

might only play a small part in affect outcomes. It might also be that the relationship

is modest because of the hypothesised protective elements that are inherently part of

co-rumination, for example the increased closeness in relationships. Rumination

appears to play a greater part in affect, it has been found to have a statistically

significant positive relationship with internalising problems with a large effect size

(Rose 2002). In some studies co-rumination does not predict psychological distress

once rumination is controlled. Additionally attachment style has also been linked to

depression (Starr & Davila, 2009). A preoccupied attachment style was found to

have a statistically significant positive relationship with depression with a large

effect size. Secure attachment style was found to have a negative relationship with

depression with a small effect size. Therefore co-rumination is likely to be one facet

of a more complex picture. Nonetheless understanding the magnitude of the

relationship between co-rumination and psychological problems may offer a helpful

perspective. From the data within studies in this review it would appear that co-

rumination has a small effect but that other factors such as rumination alone may

contribute more significantly to negative affect.

29

Nine of the sixteen studies estimated the relationship between co-rumination and

psychological problems using a cross-sectional study design. This is beneficial in

indicating the presence and magnitude of a relationship between these constructs.

However, it is not possible to infer causality from these results as they indicate a

relationship within the specific population at a specific period of time. A complex

interplay may occur between co-rumination and psychological problems in which co-

rumination could lead to psychological problems, but equally psychological

problems may lead to co-rumination, or there may be a circular relationship between

the two. The conclusion that it is possible to draw from these findings is that there

may be a relationship between co-rumination and psychological problems. In order

to explore a possible directional relationship it would be beneficial for further studies

to use longitudinal approaches and larger sample sizes, from which conclusions

could be drawn with greater confidence and external validity. Longitudinal studies

present within this review appear at times to have conflicting results regarding the

relationship between co-rumination and psychological distress. Therefore, further

longitudinal research may be helpful in reaching a more definitive consensus.

The sampling methods used within the studies reviewed, and the samples studied,

indicate that it is difficult to generalise the findings. The majority of studies recruited

children and adolescents. Whilst the focus on children and adolescents most likely

reflects the origin of the concept of co-rumination in the child and adolescent

wellbeing field, there is less evidence on co-rumination in adult samples. Research

indicates that during adolescence peer influence is greater and has been linked to risk

taking (Gardner and Stienberg, 2009), academic achievement (Mounts and

Stienburg, 1995), and substance use (Andrews et al, 2002). It might be hypothesised

30

therefore that co-rumination is most likely to impact upon psychological problems

during adolescence but may not be as significant a factor in other stages of life. The

findings of this review indicate that there is a lack of research about co-rumination in

the adult general population. Further research across a wider range of ages would be

required to understand the nature of co-rumination in the general population and how

co-rumination changes across time, ages and generations, and its potential impact on

psychological distress.

Another limitation of the current evidence base is limited cultural variability of

samples. All of the studies took place in America or Europe. Additionally, in all but

one study, the majority of the participants were Caucasian. Marked differences in

communication style have been noted across cultures (Palgrave 2012) and this may

impact both upon the occurrence and potential impact of co-rumination. For example

the American and European samples recruited could all be considered to be western,

individualist cultures. Therefore, the nature of the stressors they face or the

communication style people within these populations adopt may be different to those

faced by a collectivist community.

Areas for future study highlighted from this review would firstly be to replicate the

findings of these studies in a variety of populations. Relative to depression, fewer

studies estimate the relationship between co-rumination and anxiety, and relatively

fewer studies focus on samples of adults in the general population. Secondly, since

there is an indication that the type of the dyadic relationship may impact on the

relationship observed between co-rumination and psychological problems, further

research into different dyadic relationships may be beneficial. Finally, as theories of

31

influence suggest that our interpersonal relationships change over time, it may be

beneficial to explore how co-rumination changes across time, age and relationship.

Conclusions

Data gathered from studies reviewed indicates that there is some evidence of a

relationship between co-rumination and psychological problems, specifically those in

the category of internalising problems. The magnitude of these relationships varied

between studies, with the majority evidencing small effect sizes. However these

findings are preliminary and gathered from specific populations, which means that it

would be difficult to extrapolate and generalise these findings. Further research is

required in this area to broaden the understanding of the potential effects of co-

rumination on psychological distress.

32

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The relationship between co-rumination and depression, anxiety and social anxiety in a UK community sample.

Word Count:7278 

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Abstract

Background: Co-rumination is the process of problem discussion within a dyadic

relationship that is repetitive and unproductive with a focus on negative affect. Co-

rumination has been found to have adaptive and maladaptive facets, which result in it

being positively correlated with both negative affect and friendship quality. To date

research has focused upon relationships between co-rumination and depression

within children and adolescents using cross-sectional designs. Aim: To assess the

relationship between co-rumination, depression and anxiety in adults using a

prospective design. Methodology: This study used a two-wave prospective design

where adult participants were asked to complete an online survey (comprising

measures of rumination, co-rumination, depression, generalized anxiety and social

anxiety) at two time points three months apart. Participants rated co-rumination in

relation to the confidant they most often discuss problems with (e.g. same-sex best

friend) Findings: Positive correlations were found between the affects depression and

generalised anxiety, and co-rumination at Time 1 which became non-significant

when controlling for rumination. At Time 2, generalised anxiety exhibited this trend;

however relationships between depression and co-rumination remained significant

when controlling for rumination. No relationship was found between social anxiety

and co-rumination at either time point. When results were split by confidant type,

positive correlations were found between same-sex friend co-rumination and

depression and generalised anxiety. However, significant positive correlations

between these variables were only found at Time 2 for Romantic partner dyads.

Hierarchical linear regression found that co-rumination at Time 1 predicted

39

generalised and social anxiety at Time 2 but it was not found to be predictive for

depression. Conclusions: Cross-sectional correlational analysis supports prior

findings in the field. However prospective analysis indicated that co-rumination

predicts generalised and social anxiety but not depression. Differences in the

relationship between co-rumination and affect are observed between different

confidant types. Implications of these findings are discussed.

40

Introduction

Cognitive Behavioral Therapy (CBT) is derived from the theory that the ways in

which we think and behave impacts upon how we experience and interact with the

situations we encounter (Beck 1972). Therefore if we can understand the processes

that lead to negative affect, then changes can be implemented to improve

psychological wellbeing. Subsequently, research has explored the elements of

thought, behavior and communication that can lead to negative affects such as

depression and anxiety. The concept of rumination has a large evidence base, which

has led to interventions within CBT and other psychological therapies. More recently

co-rumination, which has conceptual overlaps with rumination, has been explored

through a number of studies and offers a new area of understanding into factors that

may impact upon psychological wellbeing.

Nolen-Hoeksema (1991) defined rumination as a way of coping with distress in

which a person engages in a repetitive thought pattern that focuses upon the causes,

consequences and symptoms of negative affect. In rumination a person adopts a

passive symptom-focused stance, instead of adopting an active problem-solving

position that might alter the cause of the distress (Mclaughlin & Hoeksema, 2011). It

has been hypothesised that whilst rumination may be a normal response to distress, it

may become difficult to control which leads to it becoming counterproductive (Hilt

& Pollak, 2013). Nolen-Hoeksema (1991) noted that people with a ruminative

response style were more prone to experiencing stress and depression following

traumatic events, and proposed that rumination may be particularly pernicious in

41

situations where a person is unable to confide in others about the cause of their

distress. Further research has supported the link between rumination and depression

(Aldao, Nolen-Hoeksema & Schweizer 2010). In addition rumination has been

linked to other elements of psychological distress including generalized anxiety and

social anxiety (Mor & Winquist 2002).

Despite the links between rumination and psychological distress, it has been

hypothesised that rumination may involve some facets that are helpful and beneficial

to affect, and others that are unhelpful and detrimental. These facets are often

respectively referred to as adaptive and maladaptive facets of rumination. Examples

of adaptive facets within the rumination literature include “reflecting” (Kane, 2009),

“problem solving” (Baars 2010) and “cognitive reframing” (Garnefski & Kraaij,

2014). These processes facilitate an increase in understanding of the problem which

may lead to improved coping (Dam, Roelofs & Muris 2014). Maladaptive facets

proposed within the rumination literature include “brooding” (Joorman, Dkane &

Gotlib, 2006), “self-immersion” (Ayduk & Kross, 2010), “self-criticism” (Green et al

2011), “catastrophising” (Garnefski & Kraaij 2014) and “stagnant deliberation”

(Scott, Yap, Francis & Schuster, 2014). These themes may be overlapping, for

example self-immersion may be linked with self-criticism and catastrophising. This

could have an impact upon affect due to the lack of an external frame of reference by

which thoughts and beliefs regarding an experience can be challenged. Brooding and

stagnant deliberation relate to the passive nature of rumination which may lead to

negative affect due to the lack of proactive action to change the situation.

42

Co-rumination is a concept proposed by Rose (2002) to describe a social

manifestation of rumination. Rose developed the concept based on the seemingly

paradoxical observation that young girls report more internalizing problems than

young boys despite having closer friendships which should, theoretically, be a

protective factor against emotional difficulties. Similarly to rumination, co-

rumination is characterised by an unproductive, repetitive focus upon a problem.

However, in contrast to rumination, co-rumination is an interpersonal process carried

out during discussion of problems within a dyadic relationship rather than an

intrapersonal process. Co-rumination has been found to take place within a variety of

dyadic relationships (Calmes and Roger 2008) and using a variety of interfaces, not

only face to face, but over the phone (Murdock, Gorman & Robbins, 2015) and via

social media (Devila et al 2012). As a result co-rumination could be present day to

day for a large number of individuals and therefore understanding its impact is

important.

Due to the conceptual overlap between rumination and co-rumination, Rose (2002)

hypothesised that the two would be likely to share properties such as having

maladaptive facets which lead to psychological distress. As with rumination,

research has attempted to draw out the adaptive and maladaptive facets of co-

rumination to better understand the process by which affect may be impacted upon.

Research has highlighted the adaptive facets of co-rumination as being “support

seeking” (Rose, 2002), “co-reflecting” (Bastin et al 2014) and “encouraging problem

talk” (Davidson et al 2014). These adaptive facets draw out the social elements of co-

rumination and link with prior research indicating that perceived social support is

linked with lower levels of depression and anxiety (Zimet et al 1988). However

43

maladaptive facets within co-rumination are thought to be “co-brooding” (Bastin et

al 2014), “mulling” (Davidson et al 2014) and “failure anticipation” (Van Zalk et al

2010). These concepts are similar to those observed within rumination and link with

the notion of unproductive affect focus leading to negative thoughts and impacting

upon psychological wellbeing.

Rose (2002) proposed that co-rumination would be associated with depression due to

the persistent negative focus on problems, and that it would be associated with

anxiety because the repetitive unproductive process would be likely to amplify worry

about the problem and uncertainty about its potential resolution. However, by its

nature co-rumination is a social activity and, as such, Rose proposed that it might

additionally have positive wellbeing outcomes due to the social interaction and

problem sharing components. As a result, Rose hypothesised that co-rumination

would be correlated both with internalising problems and friendship quality. These

hypotheses were confirmed. Statistically significant zero order positive relationships

were found between co-rumination and internalizing symptoms. When rumination

was controlled for the effect size of this relationship decreased. On the basis of

these findings Rose proposed that the relationship between co-rumination and

negative affect was due to the ruminative aspect of co-rumination. As expected

Rose found that co-rumination was positively correlated with friendship closeness.

Subsequent research has replicated Rose’s (2002) findings noting positive outcomes

in terms of friendship quality (Rose, Carison & Waller, 2007), decreased loneliness

(Mercer & DeRosier, 2010) and increased understanding leading to improved coping

(Dam, Roelofs & Muris, 2014). However research also indicates significant

44

relationships between co-rumination and measures of internalising problems such as

depression and anxiety. In a meta-analysis of the current evidence base, Spendelow,

Simonds and Avery (2016) concluded that the majority of research evidences a

relationship between co-rumination and internalising problems but that the effect

sizes found were small overall.

In their meta-analysis, Spendelow et al. (2016) highlighted a number of areas for

further research into the topic of co-rumination. Firstly, the majority of studies

reviewed were cross-sectional. Although this enables some conclusions to be drawn

regarding the co-occurrence of co-rumination and negative affect, it is not possible to

make causal inferences as the relationship observed could be bidirectional. Further

longitudinal studies would add to current evidence regarding the stability of co-

rumination over time and its potential to predict subsequent negative affect.

Secondly, Spendelow et al. (2016) observed that most of the research has focussed

on the relationship between co-rumination and depression. Little research has

focussed upon the relationship between co-rumination and anxiety despite this being

a core component of the concept of internalising problems. Although the meta-

analysis found that effect sizes for depression and anxiety did not differ significantly,

there were very few estimates for anxiety. This resulted in this aspect of the meta-

analysis being very limited with Spendelow et al. concluding that more studies were

needed to estimate the effect size for the correlation between co-rumination and

anxiety. Given that anxiety is the second most prevalent mental health condition

worldwide after depression (Vos et al 2013), understanding the processes by which it

45

may occur or perpetuate may be important as it may have therapeutic potential

including preventative interventions.

Additionally research into anxiety within the co-rumination field has tended to use a

general measure of anxiety rather than considering how co-rumination may impact

upon subtypes of anxiety such as generalised anxiety or social anxiety. Both

generalised anxiety and social anxiety have been found to have significant positive

relationships with rumination (Ruscio et al 2015; Mellings & Alden 2000). Thus

theoretically the conceptual similarities previously discussed might suggest the

likelihood of a relationship between co-rumination and these forms of anxiety.

However it is currently unknown whether the impact of the more maladaptive (i.e.

ruminative) aspects of co-rumination are offset by its proposed adaptive components

(i.e. affiliative benefits) within these subsets of anxiety. The presence of friendships

and romantic relationships, have been found to be protective against feelings of

social anxiety (La Greca & Harrison 2005). Thus it could be hypothesised that the

positive impact of social support engendered through the process of co-rumination

may outweigh the negative impact of ruminative discussion.

A third focus for further research highlighted by Spendelow et al. was whether the

relationship between co-rumination and negative affect varies dependant on

confidant type. The main focus of research to date has been co-rumination within

same-sex friendships. However, research indicates that co-rumination also occurs

between room-mates, romantic partners and with parents (Calmes and Roberts, 2008;

Grimbos, Granic & Pepler, 2013). It has been hypothesised that choice of confidant

may impact upon affect. For example, Ponce et al (2010) found that confidant type

46

may be related to development of depressive symptoms noting that males with only

peer confidants were more likely to develop depression than those who had familial

confidants. Calmes and Roberts (2008) explored the impact of confidant type and

found significant relationships between same-sex friend co-rumination and both

depression and anxiety; parent co-rumination and anxiety; and no relationships

between room-mate or romantic partner based co-rumination and either type of

affect. Despite these findings there has been little further research into the effect of

confidant type upon co-rumination.

Study Aims

The current study aimed to address gaps in the current evidence base as highlighted

by Spendelow et al. (2016). Specifically, the study used a prospective design to

estimate the relationship between co-rumination and three affects (depression,

generalized anxiety, and social anxiety), taking into account confidant type, within a

UK general population sample. Based on knowledge attained from previous research

and theory, the hypotheses for the study were as follows:

Firstly, there will be a positive correlation between co-rumination and each of the

following: depressive symptoms, generalised anxiety and social anxiety. However,

the effect size will reduce or the relationship will become negative once rumination

is controlled. This prediction is based on Rose’s (2002) suggestion that since the

components of co-rumination that are thought to impact negatively on emotional

wellbeing are shared with rumination, rumination might explain the relationship

between co-rumination and internalising problems. Rose found that both rumination

and co-rumination were positively correlated with internalising problems, but when

47

both were entered into a regression analysis rumination positively predicted negative

affect but co-rumination was associated with fewer internalising symptoms.

In addition, the study assessed whether any relationship between co-rumination and

anxiety/depression was consistent regardless of the type of confidant with whom the

participant normally discusses problems.

Secondly, in a three-month prospective analysis, initial co-rumination will predict

subsequent negative affect (either depression, social anxiety, or generalised anxiety)

after controlling for initial rumination and negative affect.

Method

Design

The study used a two-wave prospective design. Participants completed questionnaire

measures of co-rumination, rumination, depression, generalized and social anxiety at

two time-points separated by a three-month interval. Data was collected at two

time-points with the aim of assessing whether co-rumination at Time point 1

predicted subsequent reports of anxiety and depression at a later point in time.

This design is stronger than a cross-sectional regression analysis in which all

factors are measured at the same time point. Given that participants chose the

person with whom they discussed problems most frequently, it was anticipated that

during a three month interval multiple problem discussions would have been likely to

take place but that it was not such a lengthy gap that the participant would have

48

changed confidant. Thus the anticipation was that if co-rumination impacts upon

affect, as hypothesised in prior research, it would be reasonable to expect this effect

to be observed within the time parameters of the study.The survey was developed in

Qualtrics survey software (Qualtrics, 2015) and could be accessed remotely and

completed electronically. A full copy of the online questionnaire can be found in

Appendix A.

Participants

Participants were recruited from the general population using social media. The

principal method of recruitment was social media forums such as Facebook, Twitter

and Medium. A secondary recruitment method was snowballing, which was applied

by asking for the link to be shared, liked, re-tweeted or sent by email to those without

access to social media. In addition advertising within a UK university was carried out

using flyers and recruitment through the university’s online participant recruitment

system. Participants were required to be over the age of 18 and to speak English

fluently in order to complete the study measures. The aim of the sampling strategy

was to access a general adult population as much prior research had focused on

school-aged samples.

The sample size was calculated using power calculations based on the findings of

previous studies. In their meta-analysis, Spendelow et al. (2016) found that the mean

effect size for the correlation between co-rumination and anxiety was r=.22, and for

co-rumination and depression it was r=.15. In order to detect effects of this

magnitude with 80% power a sample size of N= 270 for depression and N=123 for

anxiety was required for the bivariate correlation analysis. Rose, Carlson and Waller

49

(2007) found regression R2 values ranging between .35 and .45 when predicting

internalizing problems from co-rumination. Taking an estimate of R2= .40, N=18

participants was required to detect an effect of this size using three predictor

variables at 80% power (G power; Erdfelder, Faul, & Buchner, 1996).

Measures

The online survey, which initially requested demographic information including age,

gender, education, occupation and ethnicity, was comprised of the measures detailed

below.

Co-Rumination

The Co-Rumination Questionnaire (CRQ, Rose, 2002) is a 27-item questionnaire

which assesess co-rumination within a close relationship. For example Question 1 of

the CRQ is “We spend most of our time together talking about problems that one of

us has”. Each question is scored on a 5-point scale reflecting how well the

statements given reflect the relationship in question (1=not at all true, 5= really true).

Total scores can range from 27 to 135. The higher the score, the greater the level of

co-rumination. Studies have indicated good internal consistency with Cronbach’s

alpha ranging from .90 to .95 (Rose 2002, Rose et al 2007). In contrast to the original

study by Rose (2002), which focused on close same-sex friendships, in this study,

participants were asked to select their closest confidant from a list (comprising of

same-sex friend, opposite-sex friend, intimate/romantic partner, parent or other).

They were then asked to complete the items in relation to that confidant. Following

completion of the CRQ participants were asked to rate the percentage of total

50

conversation time they felt they engaged in co-ruminative conversations, however

this variable was not used in the current analysis.

Rumination

The Rumination scale of the Responses to Depression Questionnaire (Nolen-

Hoeksema & Morrow, 1991) is a 22-item scale assessing rumination as a response to

stress. Questions are scored on a 4-point scale in which participants rate how well

they feel the statements given apply to them generally (1=almost never, 4= almost

always). Total scores can range from 22 to 88; the higher the score, the greater the

level of rumination. Research indicates an internal consistency of .95 (Nolen-

Hoeksema & Morrow, 1991).

Depressive symptoms

The Centre for Epidemiological Studies - Depression Scale (CES-D; Radloff, 1977)

is a 20-item scale assessing depressive symptoms in the previous week. Questions

are scored on a 4-point scale where participants are asked to indicate how much the

given statement has applied to them in the last week (1=rarely or none of the time,

4= most or all of the time). Total scores can range from 20 to 80. The higher the

score, the greater the level of depressive symptoms. The CES-D has demonstrated

good internal consistency (.85) (Radloff 1977).

Generalised anxiety

The Generalised Anxiety Disorder 7 (GAD-7; Spitzer, Kroenke, Williams & Lowe,

2006) is a 7-item self-report questionnaire measuring generalised anxiety. Questions

are scored on a 4-point scale where participants are asked to indicate how much the

51

given statement has applied to them in the last two weeks (1=not at all, 4= nearly

every day). Total scores can range from 7 to 28. The higher the score, the greater the

level of anxiety. It has been found to have internal consistency of .89 (Lowe et al

2008).

Social anxiety

The Social Phobia Inventory (SPIN; Connor, Kobak, Churchill, Katzelnick &

Davidson, 2001) is a 17-item, self-report measure of social phobia. Questions are

scored on a 5-point scale reflecting how well the statements given apply within the

last week (1=not at all, 5= extremely). Total scores can range from 17 to 85. The

higher the score, the greater the level of social anxiety. It has an internal consistency

of .94 (Conner et al 2000).

Ethics

Prior to starting the study participants were shown an information sheet (Appendix

A) which they were able to re-access at any time by following the original hyperlink

provided. The sheet informed participants of the study aims and procedures along

with possible advantages and disdvantages of taking part. Participants were informed

of their right to withdraw and were given information regarding the use of data.

They were provided with the researcher’s contact details and were additionally given

signposting to external sevices offering support if they felt distressed. The study was

approved by the University of Surrey Ethics Committee (Appendix B).

Procedure

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Participants accessed the online survey by following a hyperlink. The survey

commenced with the participant information screen. This was followed by the study

consent screen. Consenting participants were first presented with a question asking

their age. If a participant entered an age younger than 18 they were not able to

proceed to the survey. The survey order was as follows; descriptive data, Rumination

Scale, selection of confidant type, CRQ, rating of time spent co-ruminating, CES-D,

GAD-7 and SPIN. Having completed all survey items, participants were asked if

they would be happy to repeat the study at Time 2 (three months later). If they

agreed, they were asked to provide an email address. Email addresses provided were

then used to create electronic email lists which were used to automatically send

emails three months after Time 1 inviting the participant to take part at Time 2.

Reminders were sent a further two weeks later. All participants completed the same

measures in the same order at both Time 1 and Time 2. Participants were not

debriefed at the end of the study; instead all information was given to participants

upfront prior to starting the questionnaire. This included possible advantages and

disadvantages to participation and signposting to the researchers and external sources

of support should they wish to remove their consent or feel impacted upon due to

taking part in the study.

Analysis

Data was exported from Qualtrics study software into IBM SPSS version 23 and all

identifiers removed prior to analysis and storage. The data file was checked for

missing values and incomplete data was deleted in line with the information given in

the participant consent form. The study variables were computed, internal reliability

assessed, and distribution analysis conducted. Demographic data was analysed

53

descriptively. Correlation analysis was used to test the hypothesis that co-rumination

would be positively correlated with depression, anxiety and social anxiety scores.

Zero-order and then partial correlations were computed, to assess whether any

relationship between co-rumination and anxiety/depression changed once rumination

was partialled out. Initially, this analysis was conducted on the full dataset and then

with the dataset split by confidant type.

To assess whether co-rumination at Time 1 (T1) predicts anxiety/depression at Time

2 (T2; 3 months post T1) three hierarchical multiple regression models were run with

the outcome variable in each model being either depression at T2, generalized

anxiety at T2, or social anxiety at T2. Rumination, depression/anxiety at T1 were

entered at step one and co-rumination at T1 was entered at step two. Analysis was

restricted to the full Time 2 dataset only, rather than being conducted by confidant

type, due to there being insufficient participants for the analysis to be stratified by

confidant type.

Results

Sample Characteristics

386 participants accessed the study at Time 1. Of these participants, 274 (71%)

completed it fully (age range = 18-73, M= 35.18, SD 11.10). 84 opted to take part in

the study three months later at Time 2. Of the 84 participants who started the survey

54

at Time 2, 79 (94%) completed it (age range = 22-73, M= 38.59, SD= 13.61). Table

1 shows the descriptive characteristics of the participants at each time point.

Data from participants who did not complete the survey was not used for analysis, as

outlined in the participant information sheet. If a participant had completed and

submitted the survey, this would have been taken as consent for the information to be

analysed even if missing data was present. Within the sample of completers there

was no missing data within the measures but some participants did not provide

answers regarding descriptive characteristics. Appendix D contains graphs that

outline the stages at which participants dropped out at each time point.

Table 1: Descriptive characteristics of the sample at each time point

Descriptive factor Completed T1 only (N=274) Completed T1 & T2 (N=79)N % N %

Gender Male 41 21.1 13 16.5 Female 153 78.9 66 83.5EthnicityWhite 182 93.8 75 94.9Black 3 1.5 0 0Asian 4 2 3 3.9Chinese 2 1 0 0Mixed ethnicity 2 1 0 0Other 1 0.5 1 1.3Employment Status Employed full-time 130 67 52 65.8 Employed part-time 30 15.5 10 12.7 Unemployed 1 0.5 2 2.5 Self-employed 5 2.6 3 3.8 Student 16 8.2 0 0 Retired 6 3.1 7 8.9 Homemaker 5 2.6 3 3.8 Other 1 0.5 2 2.5

Study Measures – Descriptive Statistics

55

Prior to correlational analysis, histograms were plotted to assess the distribution of

variables (see Appendix C). Distributions of all affect variables (depression, anxiety

and social anxiety) showed positive skew as would be expected within a general

population sample. Distribution of rumination and co-rumination variables indicated

that the data was not markedly skewed. Given that parametric tests are robust to

some departures from normality, it was considered that parametric correlational

analysis would be appropriate. (Field 2009)

Assumptions of Hierarchical Linear Regression (HLM) were tested using plots to

assess the assumptions of normally distributed residuals, linearity and

homoscedasticity. These were supported for each regression (Appendix C). Variance

Inflation Factors (VIFs) were additionally used to test for multicollinearity. The VIFs

did not indicate a problem with multicollinearity.

Cronbach’s alpha was computed to assess the internal reliability of all study

measures. Table 2 outlines descriptive statistics of study measures. The Cronbach’s

alphas suggest very high internal reliability for all measures at both time points. The

mean scores on each measure were similar at each time point and the range data

suggest there was not restricted range on any of the variables.

Table 2: Descriptive characteristics of study measures

Measure Cronbach’s alpha

Items Possible range

Actual range Mean score

T1 T2 T1 T2 T1 T2Co-rumination Questionnaire

.95 .97 27 27-135 27-124 22-127 60.78 61.73

Rumination scale .91 .92 22 22-88 22-78 22-69 41.89 43.05Centre for Epidemiological Studies - Depression Scale

.92 .91 20 20-80 20-70 20-64 32.71 31.51

56

Generalised Anxiety Disorder 7

.91 .87 7 7-28 7-28 7-22 11.79 11.13

Social Phobia Inventory

.93 .94 17 17-85 17-81 17-75 30.07 30.06

Correlational analysis of full sample

Hypothesis 1 stated that there would be a positive correlation between co-rumination

and each of the following: depressive symptoms, generalised anxiety and social

anxiety. However, it was predicted that the effect size would reduce, or the

relationship would become negative, once rumination was controlled.

Zero-order and partial correlations between co-rumination and depression and

anxiety measures are displayed in Tables 3 and 4. Statistically significant positive

correlations were observed between rumination and co-rumination at both time

points with small effect sizes. Rumination was found to have a statistically

significant positive correlation with all affect measures at both time points with

medium to large effect sizes.

At Time 1, co-rumination was significantly positively correlated with both

depression and generalized anxiety with small effect sizes. However when

rumination was controlled, these correlations were non-significant. At Time 2 co-

rumination was significantly positively correlated with both depression and

generalized anxiety with small effect sizes. When rumination was controlled the

significant positive correlation between co-rumination and depression remained

although the effect size decreased. However the relationship between co-rumination

and generalized anxiety became non-significant. No statistically significant zero

order or partial correlations were observed between co-rumination and social anxiety

scores at either time point.

Table 3. Results of full sample correlational analysis at Time 1 including both zero

order and partial correlation controlling for rumination (N=274)

Variable CRQ T1 CES-D T1 GAD-7 T1 SPIN T1

Rumination T1 .23** .50** .51** .43**

57

Co-rumination T1 (zero order)

- .15* .16** .10

Co-rumination T1 (partial) - .04 .05 .00

**. Correlation is significant at the 0.01 level (2-tailed), *. Correlation is significant at the 0.05 level

(2-tailed).

Table 4. Results of full sample correlational analysis at Time 2 including both zero

order and partial correlation controlling for rumination (N=79)

Variable CRQ T2 CES-D T2 GAD-7 T2 SPIN T2

Rumination T2 .24* .56** .47** .49**

Co-rumination T2 (zero order)

- .33** .24* .17

Co-rumination T2 (partial) - .25* .16 .06

**. Correlation is significant at the 0.01 level (2-tailed), *. Correlation is significant at the 0.05 level (2-tailed).

Co-rumination vs. Depression/Anxiety by Confidant Type

Zero-order and partial correlations within Time 1 and Time 2 were calculated

stratified by confidant type. However, this analysis is not presented for every

confidant type due to small participant numbers for several confidant types (i.e.

opposite sex friend, parent and other at both time points). Given that the analysis

would be underpowered with very small subsamples, the analysis is only presented

stratified by same-sex friend and romantic partner confidants as these subgroups had

the largest sample sizes (see Tables 5-8). The findings suggested that, for same sex

friend, the most consistent finding was that co-rumination was related to depression

at both time points but that this effect reduced and became non-significant once

rumination was controlled. In contrast, with intimate partner, there were no

significant correlations between co-rumination and affect variables at Time 1. There

was also no significant relationship between rumination and co-rumination at Time 1

or at Time 2. However, at time 2, there was a significant relationship between co-

rumination and depression of a moderate effect size and there was evidence that this

remained after partialling out rumination.

58

Table 5. Results of correlational analysis for same-sex friend confidant type at Time

1 including both zero order and partial correlation controlling for rumination

(N=80)

Variable CRQ T1 CES-D T1 GAD-7 T1 SPIN T1

Rumination T1 .43** .48** .50** .46**

Co-rumination T1 (zero order)

- .30** .33** .21

Co-rumination T1 (partial)

- .12 .14 .01

**. Correlation is significant at the 0.01 level (2-tailed), *. Correlation is significant at the 0.05 level (2-tailed)

Table 6. Results of correlational analysis for same-sex friend confidant type at Time

2 including both zero order and partial correlation controlling for rumination

(N=24)

Variable CRQ T2 CES-D T2 GAD-7 T2 SPIN T2

Rumination T2 .45* .64** .33 .56**

Co-rumination T2 (zero order)

- .49* .27 .23

Co-rumination T2 (partial)

- .30 .15 -.03

**. Correlation is significant at the 0.01 level (2-tailed), *. Correlation is significant at the 0.05 level (2-tailed).

Table 7. Results of correlational analysis for intimate/romantic partner confidant

type at Time 1 including both zero order and partial correlation controlling for

rumination (N=145)

VariableCRQ T1 CES-D T1 GAD-7 T1 SPIN T1

Rumination T1 .12 .54** .46** .34**

Co-rumination T1 (zero order)

- .08 .03 .04

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Co-rumination T1 (partial)

- .02 -.03 .00

**. Correlation is significant at the 0.01 level (2-tailed), *. Correlation is significant at the 0.05 level (2-tailed).

Table 8. Results of correlational analysis for intimate/romantic partner confidant

type at Time 2 including both zero order and partial correlation controlling for

rumination (N=39)

Variable CRQ T2 CES-D T2 GAD-7 T2 SPIN T2

Rumination T2 .14 .50** .56** .50**

Co-rumination T2 (zero order)

- .34* .22 .16

Co-rumination T2 (partial)

- .31 (p=.056) .17 .11

**. Correlation is significant at the 0.01 level (2-tailed), *. Correlation is significant at the 0.05 level (2-tailed).

Hierarchical multiple regression

Hypothesis 2 stated that, in a three-month prospective analysis, initial co-rumination

would predict subsequent negative affect (either depression, social anxiety, or

generalised anxiety) after controlling for initial rumination and negative affect.

Results of HLM regression analysis can be found in Table 7. The addition of Time 1

co-rumination at Step 2 did not add significantly to the prediction of depression at

Time 2. Only Time 1 depression was a significant predictor of Time 2 depression. In

contrast, co-rumination was found to significantly account for unique variance in the

prediction of both generalized anxiety and social anxiety accounting for 4.1% and

1.4% respectively. In both models, rumination was not a significant predictor. The

regression assumptions were examined. Plots indicated that the assumptions of

normally distributed residuals, linearity and homoscedasticity were supported for

60

each regression (Appendix C). Variance Inflation Factors (VIFs) in all regressions

were below 2.

61

Table 9. Hierarchical linear regression of full sample at Time 1

B SE β t p R2 R2 Change F Change P F Change CES-DStep 1 .30 .30 16.27 .000Constant 11.71 3.87 3.03 .00CES-D T1 .39 .10 .43 3.86 .00RQ T1 .16 .10 .19 1.71 .09Step 2 .32 .02 2.47 .120Constant 8.44 4.36 1.94 .06CES-D T1 .38 .10 .42 3.82 .00RQ T1 .14 .10 .16 1.41 .16CRQ T1 .08 .05 .15 1.57 .12GAD-7Step 1 .33 .33 19.09 .000Constant 4.67 1.48 3.15 .00RQ T1 .03 .038 .075 .69 .50GAD-7 T1 .45 .092 .54 4.92 .00Step 2 .38 .04 4.97 .029Constant 2.82 1.66 1.70 .09RQ T1 .01 .04 .03 .30 .77GAD-7 T1 .44 .09 .52 4.93 .00CRQ T1 .04 .02 .21 .21 .03SPINStep 1 .75 .75 111.41 .000Constant 3.28 2.81 1.17 .25RQ T1 -.01 .07 -.01 -.09 .93SPIN T1 .89 .07 .87 13.53 .00Step 2 .76 .01 4.45 .038Constant -.01 3.15 .00 1.00RQ T1 -.04 .07 -.03 -.54 .60SPIN T1 .89 .07 .87 13.83 .00CRQ T1 .08 .04 .12 2.11 .04

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Discussion

Summary of findings

In relation to the first hypothesis of the study, that co-rumination would be positively

correlated with measures of negative affect, the correlations found at Time 1 support

the findings of Rose (2002). Significant positive correlations with small effect sizes

were found between co-rumination and affect measures for depression and

generalised anxiety. These relationships became non-significant when rumination

was controlled. This provides support for Rose’s theory that co-rumination is related

to negative affect due to its association with rumination. At Time 2, the results for

generalised anxiety also followed the pattern observed in Rose’s research. Notably

though, the zero order effect sizes observed at this time point for both generalised

anxiety and depression were greater than those observed at Time 1. Interestingly, at

Time 2 the depression results were contrary to those observed in the Time 1 sample.

Significant positive correlations with small effect sizes were seen between co-

rumination and depression, but the size and significance of the relationships were

only slightly reduced when rumination was controlled. This may indicate a

difference between the types of participants that volunteered at Time 1 only and

those that volunteered at both time points. Certain factors may make a participant

more willing to commit extra time to participating in a study at two time points.

Examples of this could be those who feel the study is of personal importance to them

given their own experiences or difficulties, or those who have an interest in

psychological wellbeing. Within this study, the mean scores for affect measures were

similar for both the Time 1 only, and Time 1 and 2 samples. So this indicates there

may not be a difference in wellbeing between the two samples. Instead, it might have

63

been that those who participated at both time points are different in their response to

problem discussion to those who only participated at Time 1; this might have

motivated their sustained participation.

In relation to the second hypothesis, multiple hierarchical regression analysis

indicated that co-rumination added to the prediction of both of generalised anxiety

and social anxiety, although by modest amounts in each instance. This indicates that

higher co-rumination predicts higher social anxiety and generalised anxiety over

time. Furthermore, rumination did not add to the prediction for either affect; this

suggests that there may be a negative component to co-rumination that is not

explained by rumination when variables are assessed over time. Therefore, whilst

correlations indicate cross-sectionally that rumination might explain the correlation

between co-rumination and negative affect, this does not appear to be the case when

the ability of co-rumination to predict negative affect at a later point in time is

assessed.

Co-rumination had a greater unique contribution to the prediction of generalised

anxiety than was seen in social anxiety, where social anxiety at Time 1 was the most

significant predictor of future affect. Social anxiety at Time 1 explains more

variability in social anxiety at Time 2, than generalised anxiety at Time 1 explains in

generalised anxiety Time 2; this may indicate that social anxiety is more likely to be

stable over time. When considering the manifestation of different types of anxiety,

the contrasting results between generalised anxiety and social anxiety may not be

surprising. Those experiencing generalised anxiety may be more prone to being

impacted upon by co-rumination, as problem-based discussion may lead to a person

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attending to new threats or worries raised by their confidant, and the discussions

around these concerns may serve to perpetuate the anxiety related cognitions and

beliefs. However in social anxiety, problem-discussion with another may be more

likely to have a beneficial effect, as the social nature of co-rumination offers an

opportunity for cognitions regarding social anxiety to be challenged or updated.

Alternatively a person with high social anxiety may be unlikely to engage in social

support seeking due to the nature of social anxiety. This lack of engagement my

serve to perpetuate the pre-existing beliefs. Thus, it is reasonable to assume that if

someone has social anxiety at Time 1, it is unlikely to have altered at Time 2.

Co-rumination was not found to significantly predict Time 2 depression.

Additionally rumination did not contribute significantly to the prediction of

depression, only Time 1 depression was a significant predictor. The findings for

depression are contrary to the previous findings regarding the link between co-

rumination and depression (Balsamo et al 2015, Criss 2016). Interestingly Nicolai,

Laney and Mezulis (2012) found that co-rumination only predicted future depression

when the problems discussed were social or dependent upon the individual. This may

indicate that the nature of conversations within the dyadic relationships may impact

upon depressive affect. As aforementioned, it was speculated that there might be

differences between the Time 1 sample and the Time 1 and 2 sample. It is possible

that these differences may account for the results seen. Alternatively, the results

could reflect the difference between cross-sectional and prospective studies in that

causality cannot be inferred from cross-sectional correlations. In this instance the

findings could suggest that those who are depressed co-ruminate more rather than the

other way around.

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Conclusions regarding confidant type are hampered by the small sample sizes in

some confidant type categories. This meant that only same-sex friend and intimate

partner confidant types could be assessed. Furthermore, the Time 2 sample sizes for

these confidant types were small, meaning that the effects observed may require

some caution in interpretation. Relationships observed from same-sex friend co-

rumination appear to mirror those observed by Rose (2002), as would be expected.

However the patterns observed between romantic partners are contrary to Rose’s

(2002) findings. Co-rumination was found not to have a significant relationship with

all affects at Time 1 and no relationship with anxiety affects at Time 2. However, co-

rumination was found to have a significant zero order correlation with depression at

Time 2, with evidence that this remained when controlling for rumination.

Additionally, rumination and co-rumination were not significantly correlated for

people who confided in their intimate partner. This suggests that co-rumination

might have a negative effect over and above rumination in intimate partner dyads.

When this is considered alongside Calmes and Roberts’ (2007) findings, there is

some evidence that co-rumination impact and processes may be different depending

upon the chosen confidant and that co-rumination may have a greater impact upon

affect within same-sex dyads than in other confidant types.

In order to understand this pattern, further research into different confidant types

would be beneficial to explore which element of the relationship dynamic leads to

co-rumination having a lesser or greater impact on negative affect. Within the results

observed in this study it could be speculated that certain key differences in dynamics

between same-sex friendships and romantic partners potentially account for the

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effects observed. For example the proportion of time spent in co-ruminative

conversations may differ. Within same-sex friendships it may be that the majority of

time spent together is focused around problem talk. However in romantic

relationships other factors occupy time together such as planning the future, intimate

moments, etc. At present there is some evidence to suggest that confidant type has a

differential impact but it would require further research to understand the factors that

lead to this observed difference.

Methodological critique

This study had a number of methodological limitations. As aforementioned, the

sample size at Time 2 was small, which may lead to analysis of this data being

underpowered. This means that some elements of analysis, such as splitting results

by confidant type, were unable to be conducted. A study being underpowered may

lead to Type Two Error (Field 2009) which impacts upon the confidence with which

a null hypothesis can be accepted.

A high attrition rate was observed. The study design and ethical approval meant that

data from non-completing participants could not be analysed. This means that factors

that may have influenced participants to complete or not remain unknown and that

partial data could not be used. It may have been beneficial to include an option, in

the participant information, to give consent to the use of incomplete data. This would

have allowed analysis of whether the completer data could be impacted upon by bias.

One factor that may have impacted upon attrition is the nature of the co-rumination

questionnaire. It is a 27 item measure in which many of the items are conceptually

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similar which may lead to the measure appearing repetitive. This could lead to

frustration and participant drop out. Shortened versions of the measure are available

however these were not used because the authors hoped to potentially use the data

gathered to perform factor analysis on the measure. To counteract the length and

repetition of the CRQ, short affect measures were chosen which are widely used

within clinical settings.

The sample used within the study may not be representative of the population due to

sampling strategies used. The use of social media snowballing and advertising within

a university setting may lead to sample bias regarding age, education level and class.

Social media may be more likely to be used predominantly by younger generations

and therefore the study may be unlikely to reach older generations, particularly

populations without internet access. Additionally advertising within a university

setting and using social media contacts of a trainee psychologist may lead to the

study being more likely to reach those within higher education settings. The

sampling strategy chosen could display bias regarding the type of people who are

likely to opt in. As aforementioned, people with an interest in the area of

psychological wellbeing, or who feel that they identify with the core concepts within

the study, may be more likely to volunteer. As a result the sample may not be

representative of the general population and therefore the generalizability of the

results could be questioned. Should the study be repeated it may be helpful to

consider ways of reaching a more representative sample for example advertising in

public places, GP surgery waiting rooms or widely read social media forums.

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This study used questionnaire measures to assess co-ruminative behaviours. This

may impact upon the reliability of the results as participants may not accurately

recall the nature of past conversations. Additionally, measures such as the co-

rumination questionnaire ask participants to think about the conversations they have

with people who they are close to. This may mean that a participant is less likely to

report something that they perceived to be negative about the other person. If this

were the case this could lead to the differences seen between confidant types. It has

been found that disclosure of abuse varies according to the relationship with the

perpetrator (Herskowitz, Horowitz & Lamb, 2005), whilst negative aspects of

conversation is a far less serious event, it could be possible that similar patterns are

observed when reporting something negative about another. It could be the case that

participants are more likely to report negative aspect of a friendship than they would

be to report negative aspects of a relationship with a romantic partner or parent. For

example the first question of the measure is related to spending the majority of time

together talking about problems, it might be that participants would either notice or

report this more in a friendship than they would in a romantic relationship or parent.

Theoretical and clinical implications

This study indicates that whilst co-rumination was developed to understand patterns

of problem talk related to affect within children and adolescents, it is a concept that

is likely to apply to and be observed across a range of ages. The study indicates that

co-rumination is linked to affect within the adult sample in a similar way to that

which has been observed in younger samples. This has implications regarding

clinical application and future research. The relationship between co-rumination and

affect in an adult population could offer new ways of understanding, assessing and

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treating adults experiencing anxiety or depression. Social support is generally

considered to be beneficial to wellbeing, but the current findings and other research

on co-rumination suggest that it is the specific nature of socially supportive

interactions that might be important. It indicates that when exploring confiding

relationships with a person it could be helpful to explore conversational habits and if

co-ruminative patterns are identified this could offer an area of therapeutic

intervention in the same way that some therapies teach clients to recognise and take

action against rumination. This could offer a new area for preventative initiatives in

psychological wellbeing.

Cross-sectional analysis from the study supports previous evidence that co-

rumination is linked with depression and generalized anxiety but indicates that it has

less likely impact upon social anxiety. However it is difficult to infer causality from

this data as it could be argued that affect may lead to co-rumination behaviours.

Prospective analysis may offer stronger evidence but has shows a different pattern. It

indicated that co-rumination added to the prediction of social anxiety and generalised

anxiety but not depression. This offers an alternative view on the relationship

between co-rumination and depression that is contrary to findings of other areas of

research in the field. Additionally these findings may indicate that the relationship

between co-rumination and different subtypes of anxiety warrants further research.

It may be of interest to extend research into other areas of anxiety, to explore how

factors within the subtype of anxiety effect the impact of co-rumination. An example

of this might be health anxiety in which the opportunity to gain external validation of

symptoms may reduce anxiety, or the exposure to other concerns could increase it.

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Within the prospective findings of this study, the non-significant contribution of

rumination to future affect challenges the conception that the negative effects seen

from co-rumination are due to ruminative processes. This could be attributed to

rumination being controlled through the use of a measure that aims to assess

rumination as an intrapersonal process, meaning that intrapersonal rumination does

not contribute to predicted affect, but that there might be a different characteristic

within interpersonal rumination that accounts for the affect seen. However it could

alternatively indicate that there is a maladaptive component of co-rumination that is

unique and contributes towards affect. This finding may indicate that further research

is needed to distinguish factors present within rumination and co-rumination and

explore how these factors relate to affect.

Building upon Rose’s (2002) original work within same-sex friendships, the findings

of this study have offered a new element by which co-rumination can be understood

by exploring the impact of confidant type. If further research replicates and expands

upon the findings of this study it could lead to a wider understanding of the factors

that cause co-rumination to impact upon affect. If co-rumination is found to be

potentially more potent in some confidant type dyads, this could allow preventative

measures to be put in place or allow therapeutic interventions to be targeted. One

area of clinical interest may be co-rumination within friendships formed in settings

such as inpatient wards where psychological distress and risk may be high.

Friendships within settings such as this could have highly beneficial or detrimental

effects upon a person’s psychological wellbeing, so by understanding the factors

within different confidant types that cause interactions to be positive or negative this

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could allow clinicians to guide their clients to assess the nature of the friendships

formed.

This research highlights that co-rumination within non-friendship based dyads is also

worth considering within clinical settings. As aforementioned, should intra-relational

dynamics impact upon the effect of co-rumination this could provide an opportunity

for therapeutic intervention or preventative psychoeducation. One area of particular

interest could be parent-child dyads. Minuchin (1974) discussed sharing of

information in relation to parent child boundary permeability. He stated that sharing

of information changes throughout age with boundaries, originally being

impermeable between a parent and young child but changing to become more

permeable as the child grows up. The theory indicates that difficulties may arise in

relationships where the dyad is ‘enmeshed’ and information is shared freely. This

theory may overlap with that of co-rumination and it would be conceptually

interesting to increase understanding regarding whether co-ruminative

communication styles may impact upon the affects observed within ‘enmenshed’

relationships or as relationship boundaries change over time. Additionally it may be

helpful to understand whether the premise of a relationship effects the impact of co-

rumination. For example if co-ruminative romantic relationships are found not to

have the same impact as co-ruminative friendships could this be due to the

expectation that within friendships you meet up to discuss current events where as

romantic relationships may be more multifaceted.

Future research

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The findings of this study and those of Calmes and Roberts (2008) indicate that

further research into the impact of confidant type would be beneficial. Studies into

this area would require large sample size in order to retain power when data is split

by confidant type. To understand the differences observed it may also be

advantageous for future studies to collect information regarding the nature of co-

ruminative conversations to gain an idea of whether this is a factor in the differences

observed between confidant types.

The current research based is predominantly quantitative using questionnaire

measures. In order to build understanding and develop future therapeutic

interventions it may be helpful to use different research methods, such as

experimental and qualitative designs. For example, observing conversations or using

discourse analysis of conversations held on social media. These methods may give

more detailed information regarding the content of conversations and clarify which

elements of conversation lead to negative affect. This information could be

operationalized within a therapeutic setting, for example by considering time spend

discussing problems, presence of negative focus or exploring if the conversations

adopt a passive or active stance to problem solving. Additionally direct observation

may reduce the likelihood of bias occurring through the use of self-report measures,

which may be particularly evident when participants are asked to disclose potentially

negative communication styles with people whom they are close to.

Since the current literature base is predominantly centred on children and adolescents

it would be beneficial to further explore co-rumination within adult samples to verify

and extend the findings of this study. In light of the relatively small number of

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participants over the age of seventy participating in this study due to the sampling

limitations mentioned above, it would be beneficial to engage samples within older

populations to observe how co-rumination manifests in different ages in relation to

impact and confidant type. Research indicates that social support changes over the

life span and that in later life relationships with spouses and family members increase

in interaction frequency and emotional closeness (Tilburg 1998; Carstensen 1992). It

could be hypothesised that co-rumination patterns are likely to change and adapt

according to the context of the social support available.

Additionally, there is currently a deficit in longitudinal studies within this field of

research (Spendelow et al 2016). As mentioned above social support changes over a

lifespan and therefore it could be proposed that co-rumination is also likely to. It

would be interesting to explore if any fluctuations in co-ruminative behaviour are

due to external or internal processes; in other words, is co-rumination a

communication style that is innate to the person or is it influenced by others

communication styles, particular life stressors etc. Longitudinal research would

additionally give indication regarding causal sequence to build upon single time

period observations in cross-sectional research.

Conclusions

This study replicates the findings of Rose (2002) regarding cross-sectional

correlations in same-sex friend-based co-rumination. However using a prospective

design it found that whilst co-rumination in part predicted future generalised anxiety

and social anxiety, it did not predict future depression. Additionally rumination was

not found to predict any affect measures indicating that there may be a unique

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contributing factor within co-rumination that leads to negative affect. The study

additionally built upon evidence that confidant type chosen for co-rumination may

impact upon the affect observed. Whilst these findings may contribute to the current

understanding of co-rumination, the field currently requires further research to better

understand the processes involved which lead to negative affect.

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List of Appendices

Appendix A: Copy of online questionnaire including participant information and

consent sheet and all measures.

Appendix B: Ethical approval letter

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Appendix C: Tests of statistical assumptions

Appendix D: Graphs of participant drop out

Appendix A - Copy of online questionnaire from Qualtrics

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Problem Discussion and Emotional Wellbeing Study Information for Participants

Introduction We are researchers at the University of Surrey, Guildford. This information screen is intended to make you aware of research we are conducting and provide you with essential information to help you in determining whether you wish to participate. Before you decide, you need to understand why the research is being done and what it will involve for you. Please take the time to read the following information carefully. Talk to others about the study if you wish.  

What is the purpose of the study? To look at the effect of discussing personal problems with a close friend on people’s emotional wellbeing.  

Why have I been invited to take part in the study? We are inviting women and men over the age of 18 who speak English to take part.  

Do I have to take part?No, your participation is completely voluntary. You can also withdraw during the study without giving a reason, even if you have started taking part. The study has two stages separated by 3 months.  You do not have to take part in the second stage even if you do take part in the first stage. If you withdraw from the study before completing a stage, any information provided by you to that point in the stage will be deleted and not included in the data analysis.  If you submit complete data for a stage then it will be assumed that you give permission for us to use the data you have submitted.  

What will happen to me if I take part? You will be invited to complete an on-line survey asking a number of questions of relevance to this research. The questions are presented as a series of statements asking your degree of agreement with each one. These statements will cover various topics including how you talk to others about personal difficulties, how you think about these yourself, and your emotional well-being such as feelings of anxiety and depression. The survey is expected to take approximately 20 minutes to complete. If you think you might find it upsetting to think about these issues, we advise you do not take part.  At the end of the survey we will ask if you would be willing to complete the survey again, in about 3 months time.  You do not have to agree to this.  

What are the possible disadvantages or risks of taking part?

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Unpleasant emotional reactions to the survey are not likely, however, it is possible that some of the statements you respond to could make you think about upsetting feelings. If you would like urgent support, you can contact the Samaritans on 08457 90 90 90 or jo@samaritans.org. For general information and support about mental health issues, you can also visit MIND, www.mind.org.uk.   

What are the possible benefits of taking part? An opportunity to be involved in research that helps improve our understanding of discussing personal difficulties with others and the effects on personal well-being.  All participants who request a summary of the study findings will be sent this at the end of the study. We estimate this will be in October 2016.  

What happens with the information you provide?Survey responses you provide will be securely stored on University of Surrey computer servers. Any personal data you supply will be separated from your survey responses and stored securely. This means your survey responses will be anonymised. Once all of the information provided by participants has been entered into a database, everybody’s responses will be statistically analysed. The information you provide may be used in written materials/publications (e.g., academic journals) and presentations at conferences or other events. However, no individual identifying information will be used when presenting the findings. Study data will be stored securely for a minimum of 10 years and only people with direct interest in this research will be granted access to the information. No-one will be allowed access to your personal data except the research team.  

What if there is a problem? Any complaint or concern about any aspect of the way you have been dealt with during the course of the study will be addressed; please contact Nicola Griffiths on n.griffiths@surrey.ac.uk. You can also direct any comments or complaints to Mary John, PsychD Programme Director on m.john@surrey.ac.uk  

Will my taking part in the study be kept confidential? Yes. All of the information you give will be anonymised so that those reading reports from the research will not know who has contributed to it. Personal data will be stored securely in accordance with the Data Protection Act 1998.  

Contact details of researchers Nicola GriffithsTrainee Clinical Psychologist Email: n.griffiths@surrey.ac.uk  

Who is organising and funding the research? This research is being organised by the study investigators listed above. There is no funding provided for this research.  

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Who has reviewed the project? The study has been reviewed and received a favourable ethical opinion from the University of Surrey Ethics Committee.    

Thank you for taking the time to read this Information Sheet.

Problem Discussion and Emotional Wellbeing Study Consent Form

I voluntarily agree to take part in the study on problem discussion and emotional wellbeing.                                       

I have read and understood the participant information provided. I have been given a full explanation by the investigators of the nature, purpose, and likely duration of the study, and of what I will be expected to do. I have been advised about any discomfort and possible ill-effects on my health and well-being which may result. I have been given the opportunity to ask questions on all aspects of the study and have understood the advice and information given as a result.              

I consent to my personal data, as outlined in the above information sheet, being used for this study. I understand that all personal data relating to volunteers is held and processed in the strictest confidence, and in accordance with the Data Protection Act (1998).                                                                                  

I understand that I am free to withdraw from the study  without needing to justify my decision and without prejudice. If I withdraw from the study before completing the survey, none of the answers I have supplied will be used in the study.  

I confirm that I have read and understood the above and freely consent to participating in this study.  I have been given adequate time to consider my participation and agree to comply with the instructions and restrictions of the study.  

I am aged 18 years or older.    

By clicking the ‘Yes’ button below you consent to taking part in this study. If you do not wish to take part, please click on the ‘No’ button below.  

Yes (1) No (2)If No Is Selected, Then Skip To End of Survey

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Age What is your age? (Please note: You need to be at least 18 years to participate in this questionnaire)If What is your age? Is Less Than 18, Then Skip To End of Survey

Gender What is your gender? Male (1) Female (2)

RS What is your relationship status? Married/Civil Partnership (1) Single (2) Widowed (3) Separated/Divorced (4) Co-habitating (5) Other: (6) ____________________

Empl What is your employment status? Employed full-time (1) Employed part-time (2) Unemployed (3) Self-employed (4) Student (5) Retired (6) Homemaker (7) Other: (8) ____________________

Qual What is your highest educational qualification?

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Ethnicity What ethnicity do you consider yourself to be? British (1) Irish (2) European (3) Other: (4) ____________________ Caribbean (5) African (6) Other: (7) ____________________ Indian (8) Pakistani (9) Bangladeshi (10) Other: (11) ____________________ Chinese (12) Chinese British (13) White & Black Caribbean (14) White & Black African (15) White & Asian (16) Other: (17) ____________________ Other: (18) ____________________

RQ People think and do many different things when they feel depressed. Please read each of the items below and indicate whether you almost never, sometimes, often, or almost always think or do each one when you feel down, sad, or depressed. Please indicate what you generally do, not what you think you should do.

Questionnaire removed due to copyright

CRQCC Who is your closet confidant? This is the person you are most likely to talk to when you have emotional problems. Select one of the following: Same-sex friend (1) Opposite-sex friend (2) Intimate/romantic partner (3) Parent (4) Other: (5) ____________________

CRQ Think about the way you usually are with your closest confidant. Indicate your response for each of the following statements that best describes you.

Questionnaire removed due to copyright

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CRTT You have been asked to think about the above conversation topics in relation to your closest confidant. Now estimate how much time you spend on these types of conversations in total with all the people you know in your life (e.g., 50% of all my conversations with all the people I know involve the above topics).______ Percentage of time (1)

CES-D Below is a list of some ways you may have felt or behaved. Please indicate how often you have felt this way during the last week by checking the appropriate space. Please only provide one answer to each question.

Questionnaire removed due to copyright

GAD7 Over the last 2 weeks, how often have you been bothered by any of the following problems?

Questionnaire removed due to copyright

SPIN Please indicate how much the following problems have bothered you during the past week. Mark only one box for each problem, and be sure to answer all items.

Questionnaire removed due to copyright

Info Thank you for completing this questionnaire. If you are happy to complete this questionnaire again in three months, please place your contact details below. As stated earlier, your participation in three months is completely voluntary and you can change your mind about participating.

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Appendix B – Letter of Ethical Approval

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Appendix C - Tests of statistical assumptions

Distribution of CRQ at T1 and T2

Distribution of RQ at T1 and T2

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Distribution of CES-D at T1 and T2

Distribution of GAD-7 at T1 and T2

Distribution of SPIN at T1 and T2

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CES-D Residuals

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GAD-7 Residuals

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SPIN Residuals

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Appendix D: Graphs of participant drop out

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Part Three - Summary of Clinical Experience

Adult PlacementMy first placement was in a Community Mental Health Team (CMHT). During this placement I gained experience in Cognitive Behavioural Therapy (CBT) working with adults of various ages and complex and enduring mental health difficulties. I worked therapeutically with individuals with Depression, Psychosis, Anxiety, Borderline Personality Disorders, Complex Grief, and Trauma. I co-facilitated a STEPS group and developed information resources on PTSD for the team.  I conducted two neuropsychological assessments using the WAIS-IV including taking developmental histories and conducting feedback sessions with a formulation and associated recommendations. Additionally I used the following standardised measures in my clinical practise: CORE, Rosenberg Self esteem Scale, BAI, BDI.

Learning Disabilities Placement     My second placement was in a Community Mental Health Team for people with a Learning Disability. I delivered systemic, indirect and direct1:1 interventions using adapted Cognitive Behavioural Therapy, Cognitive Analytical Therapy, Positive Behavioural Support and systemic approaches. I worked with clients presenting with depression, anxiety, anger, challenging behaviours and adjustment issues. I worked collaboratively with staff in residential care homes to support them with understanding and managing clients challenging behaviours. I also carried out two cognitive assessments using the WAIS-IV and ABBAS-III as well as the CORE-LD, HALO, Glasgow Anxiety Scale LD, Glasgow Depression Scale LD.I gave a presentation to the team about cognitive assessment of learning disabilities in accordance with the recent BPS guidance and gave a training session about emotion regulation skills to teachers at a college. I worked collaboratively with Nursing and speech and Language Therapy including conducting capacity assessments. 

Older Adults Placement   My third placement was working across four Community Mental Health Teams for Older Adults and an Inpatient Ward for Older adults with functional mental health difficulties. As part of the CMHRS, I gained experience in assessing older adults and working therapeutically using an integrative approach incorporating the following models; CBT, reminiscence, systemic and recovery model. I worked with Older adults experiencing a range of difficulties including Depression, Anxiety, OCD, Dementia, Bipolar Disorder, Complex Grief and Trauma I carried out two dementia assessments using a full battery of neuropsychological tests to include: TOPF, WAIS-IV, WMS-IV, ACE-III, KBNA, DKEFS, RBANS, BADS, graded Naming Test. I also co-facilitated a psycheducation group for older

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adults on an inpatient ward. I conducted an audit of neuropsychology reports with psychologist and psychiatrists and fed back the results with an aim of making neuropsychology reports more accessible and time efficient. Specialist Placement   My specialist placement was with a charity providing support for military veterans experiencing PTSD. Within this placement I worked with individuals using Trauma Focussed CBT to work through trauma and facilitated psychoeducation groups about PTSD. I also worked with veterans through both individual and group work to address difficulties with emotion regulation.

 CAMHS PlacementMy final placement was in a Child and Adolescent Mental Health Service. During this placement I worked individually with young people and with their family members. I used adapted CBT, Compassion Focussed therapy and elements of narrative therapy and Dialectical behavioural Therapy. I worked as part of family therapy team working with family of a child experiencing thoughts of suicide and self-harm. I completed two cognitive assessments using the WISC-IV, WIAT and ABAS-III, as well as the RCADS, SDQ, OCI and Goal Based Outcomes. I also took part in the observation and scoring of an ABAS. I worked with a range of professionals including psychiatrists, family therapists, art therapists, teachers and social workers. I worked with the team to develop a new waiting list system that I implemented during my placement. 

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Part Four - Table of Assessments Completed During Training

Year I AssessmentsASSESSMENT TITLE

WAIS WAIS Interpretation (online assessment)Practice Report of Clinical Activity

Practice Report of Clinical Activity with Ms Alice Jones, a Female Client in her 30’s Experiencing Depression with a Co-Morbid Eating Disorder

Audio Recording of Clinical Activity with Critical Appraisal

An Audio Recording of a First CBT Intervention Session with a Lady Experiencing Low Mood Following Pharmaceutical Intervention for her Diagnosis of Bipolar Disorder.

Report of Clinical Activity N=1

A Report of Clinical activity of work carried out with a Lady in her 50’s Experiencing Low Mood Following Pharmaceutical Intervention for Bipolar Disorder

Major Research Project Literature Survey

A Literature Survey Exploring Current Research on the Adaptive and Maladaptive Components of Co-Rumination

Major Research Project Proposal

Working Title of Proposed Study: Exploring the impact of Co- Rumination in the General Population and a Factor Analytic Exploration of the Co-Rumination Questionnaire

Service-Related Project Evaluating Three Course Handbooks of A University PsychD Clinical Psychology Course – A Trainee Perspective

Year II AssessmentsASSESSMENT TITLE

Report of Clinical Activity/Report of Clinical Activity – Formal Assessment

A Case Report of Clinical Activity Discussing a Cognitive Assessment with a Man in his 30s with an Intellectual Disability due to Down’s Syndrome

PPLD Process Account A Reflective Account of the Process of Attending a Personal and Professional Development Group

Year III Assessments ASSESSMENT TITLE

Presentation of Clinical Activity

An integrated intervention for a lady in her 80’s experiencing anxiety in the community having returned

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home from an inpatient admissionMajor Research Project Literature Review

The Relationship between Co-Rumination and Psychological Distress

Major Research Project Empirical Paper

The relationship between co-rumination and depression, anxiety and social anxiety in a UK community sample.

Report of Clinical Activity/Report of Clinical Activity – Formal Assessment

A case report on using trauma focused cognitive behavioural therapy with a male army veteran in his 30's with a diagnosis of Post Traumatic Stress Disorder (PTSD). 

Final Reflective Account

On becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of training

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