A meta-analysis and systematic review of Memory Specificity Training (MeST) in the treatment of emotional disorders
Introduction
Cognitive-behavioural therapy (CBT) for emotional disorders such as Major Depressive Disorder (MDD) is effective and yet it is imperfect (Cuijpers, Cristea, Karyotaki, Reijnders, & Huibers, 2016; Linde et al., 2015). For example, CBT shows very large effect sizes in the treatment of MDD when considering evidence from randomised controlled trials (g = 0.75; Cuijpers et al., 2016). However, when one takes into account the presence of publication bias in this literature, as well as the use of inadequate, passive controls (e.g., wait-list), and other aspects of poor research quality (e.g., poor blinding, randomization and management of incomplete data), effect sizes become small to moderate in the treatment of depression (g = 0.43) and other emotional disorders (Cuijpers et al., 2016). Furthermore, the effects of CBT in treating depression are comparable to other common talking therapies (Linde et al., 2015). Some authors have concluded that greater focus must now be given to developing interventions that target specific mechanisms associated with disorder maintenance, such as those related to cognitive impairments in memory or attention, rather than the non-targeted, fix-all approach of CBT (Craske, 2018). Such interventions might also offer promise in the prevention of emotional disorders as many cognitive impairments are also associated with disorder vulnerability and yet little is currently done to target these mechanisms and prevent the emergence of emotional disorders (van Zoonen et al., 2014). There is also some suggestion that universal, non-targeted prevention programmes may be less effective than approaches which target particular disorder mechanisms (Werner-Seidler, Perry, Calear, Newby, & Christensen, 2017). One such targeted intervention that has been used to both prevent and treat emotional disorder is Memory Specificity Training (MeST; Raes, Williams, & Hermans, 2009).
MeST offers promise in both treatment and prevention given the breadth of research suggesting that the reduced autobiographical memory specificity (rAMS) which it targets, is evident amongst people with depression and other clinical diagnoses (Van Vreeswijk & De Wilde, 2004) and can predict increases in symptom severity across time (Kleim & Ehlers, 2008; Sumner, Griffith, & Mineka, 2010). By improving memory specificity problems through intervention, we would therefore expect a commensurate improvement in the symptoms of emotional disorder in currently symptomatic people, or a reduction in the likelihood of acquiring a diagnosis in those people not currently symptomatic. However, one must ask how MeST has been delivered, how it has been investigated and how effective it has been in improving symptoms and other outcomes. From this one must ask whether MeST or its investigation can be improved and what form such improvements might take. The present meta-analysis and systematic review sought to answer these questions by collating and reviewing all existing evidence regarding MeST and other interventions within which components of MeST can be found.
It is of note that there has been a recent review of the broader literature of memory training protocols (Hitchcock, Werner-Seidler, Blackwell, & Dalgleish, 2017). However, this review excluded studies that did not include control comparisons and which involved healthy participants or participants with diagnoses other than depressive and anxious disorders. As such, they included three interventions that trained memory specificity (Moradi et al., 2014; Neshat-Doost et al., 2013; Serrano, Latorre, Gatz, & Montanes, 2004) and did not evaluate the full breadth of available MeST literature.
In order to fully evaluate MeST we must first consider what rAMS is, what causes it and how MeST attempts to improve it. rAMS – or overgeneral memory – refers to the difficulty some people have in recalling specific experiences from their past. Individual differences in memory specificity are typically assessed using the Autobiographical Memory Test (AMT) where participants are given several cue words of positive, negative or neutral valence and they are asked to recall a memory related to this cue (Williams & Broadbent, 1986). Although there is debate regarding the way in which AMT responses should then be coded, the overwhelming psychometric consensus is that individual differences in specificity are best operationalised as the number, or proportion of memories recalled within the AMT that are specific, or those which involve a single event lasting 24 h or less (Griffith et al., 2009; Griffith et al., 2012; Heron et al., 2012; Takano, Gutenbrunner, Martens, Salmon, & Raes, 2017). MeST therefore seeks to increase the number or proportion of specific memories recalled from pre-to post-intervention.
It is also important to consider processes which are thought to reduce memory specificity, as well as those which are thought to be a consequence of rAMS and which mediate its association with emotional disorders. Many of these processes are measured within MeST investigations and so we might also evaluate the extent to which MeST influences these processes. In accordance with Conway and Pleydell-Pierce’s (2000) model of memory retrieval, Williams (2006) and Williams et al. (2007) suggested that memory retrieval follows a hierarchical process where abstract, categorical themes are first retrieved and then specific, concrete events are retrieved. rAMS is therefore characterised by retrieval that fails to work its way past the abstract level. Williams (2006) CaRFAX model suggested three pathways through which this can occur, each of which is thought to be a prominent feature of emotional disorders: Capture and Rumination, Functional Avoidance and impaired eXecutive functioning. During retrieval of a memory related to a cue, a depressed person might be Captured by, and then Ruminate on, semantically-associated, self-related, negative conceptual themes (e.g., attempts to retrieve a memory of a fun time may evoke thoughts of being boring) or categories of events (e.g., when one's grandchildren used to visit them). This ruminative thinking is repetitive, self-concerned and unconstructive. Also, one might try to avoid specific events in one's memories, for fear that such memories might evoke negative feelings – so called Functional Avoidance (e.g., one might avoid recalling memories of specific social gatherings for fear that one might retrieve a memory of a negative encounter that occurred). The final pathway, impaired eXecutive functioning, is suggested to compromise retrieval independently of the other pathways. A person with weak executive functioning may be less able than a person with strong functioning to hold a specific memory in mind during retrieval or to update this memory as other memories are retrieved (Sumner, 2012). They may also be less able to inhibit distraction by irrelevant thoughts or other ongoing events when they are trying to retrieve a memory or when they are trying to verbalise it (Sumner, 2012).
Through these three pathways, and the interaction between or combination of pathways, memory specificity comes to be comprised, with several consequences that may in turn lead to emotional disorder. First, reduced specificity may compromise one's abilities to solve problems as one is less able to use information from previous events to inform the selection of solutions for ongoing problems (Arie, Apter, Orbach, Yefet, & Zalzman, 2008). This is also thought to compromise one's ability to imagine and plan for one's personal future, leading to feelings of hopelessness and excessively negative views regarding one's future (Arie et al., 2008; Evans, Williams, O'loughlin, & Howells, 1992). Relatedly, rAMS may also encourage one to think in a more verbal, ruminative manner (Raes, Williams, & Hermans, 2008) and prevent one from thinking in a more constructive imagery-based manner (Holmes, Blackwell, Burnett Heyes, Renner, & Raes, 2016). Also, by not recalling specific negative events that have happened in our past, this is thought to reduce exposure to negative emotional experiences and so restricting one's ability to learn how to regulate and cope with these emotions when they are inevitably evoked (Harris et al., 2015; Hermans, Raes, & Eelen, 2005).
MeST research has therefore not only examined the effects of MeST on memory specificity and the symptoms of emotional disorders, but also its effects on the processes associated with reduced specificity. Our review therefore considers evidence regarding these other processes where it exists.
The present meta-analysis and systematic review provides the first synthesis of all existing studies in which MeST has been tested within the context of emotional disorders. Following the initial search for and extraction of data, the review begins with a detailed introduction to MeST and the ways in which it has been translated and implemented. The effects of MeST on individual differences in memory specificity, the symptoms of emotional disorders and other associated processes are then analysed. Our discussion then synthesises these findings and considers the current state of MeST and future directions.
Section snippets
Review strategy, inclusion criteria and data extraction
All studies were sampled from the authors' personal libraries (k = 12; one study reported two relevant intervention groups so final k = 13). Studies were included in the review if they involved a training protocol for enhancing the specificity of autobiographical memory amongst participants and where there was an assessment of change in the symptoms of emotional disorders. Studies were not included in this review if they involved memory training amongst participants characterised by cognitive
What is memory specificity training?
Serrano et al. (2004) presented the first implementation of a protocol for training memory specificity. However, their protocol was included within a wider programme of Life Review Therapy. The first implementation of a dedicated protocol for Memory Specificity Training was conducted by Raes et al. (2009) in their pilot investigation of MeST amongst depressed inpatients. This study comprised of four, 1-h group sessions. Although other MeST investigations differ in terms of the number and length
Discussion
The present review considered the breadth of available literature regarding the effects of memory specificity training on problems with autobiographical memory specificity and the symptoms of emotional disorders and other associated processes. In our meta-analysis, MeST was associated with substantial improvement in memory specificity and depressive symptoms and outperformed passive control groups, and to a lesser extent active control groups, at post-intervention assessment. However, across
Conclusion
In overview, MeST holds promise as a novel and targeted intervention for improving reduced autobiographical memory specificity (rAMS) and the symptoms of emotional disorder. However, our meta-analysis suggests that many of its effects are transitory, and do not persist into follow-up assessment. Future research is warranted. Strategies to enhance MeST's effects could be adopted and larger and more varied samples of participants could be employed, with control groups that allow for more robust
Disclosures
This manuscript was not supported by any external funding. The authors have no conflicts of interest to acknowledge.
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2023, Journal of Behavior Therapy and Experimental PsychiatryCitation Excerpt :Further, by using a sample with remitted MDE's and no current clinically-significant depressive symptoms, this would also test whether OGM deficits and associated differences in retrieval processes persist when people are otherwise psychiatrically healthy. This would indicate a persistent cognitive vulnerability for future depressive episodes, reinforce the evidence from previous studies, and indicate ways to optimize memory therapeutics for clinical depression (Barry, Sze, & Raes, 2019, 2021; Hallford et al., 2021; Hitchcock et al., 2016, 2017; Raes et al., 2009). For instance, suppression of direct retrieval of negative categoric memories may be important in the treatment of depression and prevention of relapse, and no such technique has been specifically used to date.