Key Constructs in Classical” and New Wave” Cognitive Behavio.docx

Key Constructs in “Classical” and “New Wave” Cognitive
Behavioral
Psychotherapies: Relationships Among Each Other
and With Emotional Distress
Ioana A. Cristea,1,2 Guy H. Montgomery,3 Ştefan Szamoskozi,1
and Daniel David1,3
1 Babes-Bolyai University, Cluj-Napoca
2 University of Pisa
3 Mount Sinai School of Medicine
Objective: We aimed to relate key constructs from three forms
of cognitive behavioral ther-
apy that are often placed in competition: rational emotive
behavior therapy, cognitive therapy, and
acceptance and commitment therapy. The key constructs of the
underlying theories (i.e., irrational
beliefs/unconditional self-acceptance, dysfunctional cognitions,
experiential avoidance/psychological
inflexibility) of these therapies have not been explicitly studied
in their relationships to each other and
with emotional distress. Method: We used a cross-sectional
design. The variables were selected
to indicate key constructs of the three major forms of therapy
considered. Study 1 used a sample of
152 students, who were assessed during a stressful period of
their semester (mean age = 21.71;
118 females), while Study 2 used a clinical sample of 28
patients with generalized anxiety disorder
(mean age = 26.67; 26 females). Results: Results showed that
these constructs, central in the

therapies considered, had medium to high associations to each
other and to distress. Experiential
avoidance was found to mediate the relationship between the
other, schema-type cognitive constructs
and emotional distress. Moreover, multiple mediation analysis
in Study 2 seemed to indicate that the
influence of the more general constructs on distress was
mediated by experiential avoidance, whose
effect seemed to be carried on further by automatic thoughts
that were the most proximal to distress.
Conclusions: Although each of the cognitive constructs
considered comes with its underlying
theory, the relationships between them can no longer be ignored
and cognitive behavioral therapy
theoretical models reliably accounting for these relationships
should be proposed and tested. C© 2013
Wiley Periodicals, Inc. J. Clin. Psychol. 69:584–599, 2013.
Keywords: cognitive behavioral psychotherapy; rational-
emotive behavioral therapy; cognitive therapy;
acceptance and commitment therapy; mediation
Cognitive behavioral therapy (CBT) is one of the fastest
developing fields in psychotherapy.
Emerging from the “classical” CBT paradigm (e.g., Beck, 1976;
Ellis, 1962), new forms of CBT,
sometimes called the “third wave” or the “new wave,” have
been developed (Hayes, 2004). Their
shift relates to changing the way we look at the very basis of
CBT, namely, the status of cognitive
change.
Clark (1995), in common with other leading cognitive therapists
asserts that a fundamental
postulate of the cognitive model of psychopathology is that
cognitive change is central to treating

psychological disorders, stating that “all therapies work by
altering dysfunctional cognitions,
either directly or indirectly” (p. 158). While they still view
cognitions as highly relevant to
psychopathology, third wave CBTs consider change in cognitive
content as nonessential in
We thank Dr. Aurora Szentagotai Tatar and Dr. Florin Alin Sava
for valuable consultation regarding the
adaptation of the AAQ-II, Dr. Krisztina Szabo for providing the
study database for the Romanian adaptation
of the AAQ-II, as well as Dr. Andrew Hayes and Dr. Kristopher
Preacher for important advice on mediation
procedures.
Please address correspondence to: Ioana A. Cristea, Babes-
Bolyai University, Department of Clin-
ical Psychology and Psychotherapy, No.37, Republicii St.,
400015, Cluj-Napoca, Romania. E-mail:
[email protected]
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 69(6), 584–599
(2013) C© 2013 Wiley Periodicals, Inc.
Published online in Wiley Online Library
(wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21976
Key Constructs in Cognitive Behavioral Therapies 585
producing therapeutic change. More precisely, from this
perspective, while thoughts are still
essential in causing and maintaining emotional disorders, the
objective of therapy is not to alter
the actual content of dysfunctional thoughts, but to transform
their function in determining
psychopathology, by modifying the individual’s relationship to

these thoughts. As such, these
third wave CBTs choose to focus on different processes (e.g.,
psychological flexibility, acceptance,
defusion) that employ a more experiential approach to the
clients’ beliefs.
The classical and the third wave CBT perspectives seem to each
be working on their own,
diverging theories as part of the same broad paradigm. Classical
CBT focuses on measuring
cognitive change (i.e., changes in measures of cognitive
constructs, such as dysfunctional
beliefs) and relating it to changes in therapeutically relevant
outcomes, such as distress or
measures of specific psychopathology. Third wave CBTs focus
on measuring processes other
than cognitive change (e.g., experiential avoidance), deemed as
etiologically relevant in causing
psychopathology, and relating these processes to very similar
outcomes.
The Classic Wave in Cognitive Behavioral Psychotherapy
Rational emotive behavior therapy (REBT). The first form of
CBT, REBT’s model
states that it is not the event itself causing our emotional states,
but our beliefs related to
that event. Regarding beliefs, it distinguishes between two key
evaluation/appraisal “styles”:
irrational and rational. The irrational evaluations are not
logical, do not have factual support
in reality, and/or hinder the person from achieving his/her
goals, while the rational ones are
logical, have empirical support, and/or help the person achieve
his/her goals. The REBT
therapeutic stance involves changing the patient’s dysfunctional

emotions and behaviors by
means of changing the irrational beliefs into rational ones and
by promoting the patient’s
unconditional self-acceptance (David, Montgomery, Macavei, &
Bovbjerg, 2005). Studies have
linked irrationality to state anxiety, anger, guilt (David, Schnur,
& Belloiu, 2002), state anger
(Martin & Dahlen, 2004), and exam-related distress
(Montgomery, David, DiLorenzo, & Schnur,
2007). Irrationality was also linked to psychopathology, such as
depressive symptoms (Chang,
1997), major depressive disorder (Solomon, Arnow, Gotlib, &
Wind, 2003), and clinical anxiety
(Muran & Motta, 1993).
Cognitive therapy (CT). The basic difference between the REBT
and the CT (Beck, 1976)
therapeutic stances lies in their chief focus on one category of
thoughts–“hot” versus “cold”
cognitions (David, Miclea, & Opre, 2004). Beck’s CT focuses
primarily on “cold” cognitions,
mental representations of relevant circumstances (Lazarus,
1991), in the forms of dysfunctional
descriptions and inferences. The difference between these two is
that, whereas descriptions
merely present an observed fact (e.g., “It’s 10 o’clock and my
wife is not home”), inferences
extend further from the perceived fact (e.g., “The fact that she
is not home at this hour shows
she is having an affair”–“jumping to conclusion” dysfunctional
belief). In contrast, therapies
such as REBT focus mainly on “hot” cognitions in the form of
evaluations (appraisals), which
refer to the ways in which “cold” cognitions/representations are
processed in terms of their
relevance for personal well-being (Lazarus, 1991; e.g., “The

fact that she is having an affair is
catastrophic for me”–“awfulizing” irrational belief). Studies
have linked dysfunctional attitudes
to distress, such as depression, anxiety, and hostility (Whittal &
Dobson, 1991) and depressed
mood (Henriques & Leitenberg, 2002). They have also been
related to psychopathology, such as
depression (de Graaf, Roelofs & Huibers, 2009), hypomania
(Lex, Hautzinger & Meyer, 2011),
and bipolar disorders (Perich, Manicavasagar, Mitchell, & Ball,
2011).
The New Wave in Cognitive Behavior Psychotherapy
Acceptance and commitment therapy (ACT). ACT is one of the
most visible new wave
CBTs, especially regarding the investigation of its proposed
theory. New wave CBTs downplay
the importance of explicit cognitive restructuring/challenging of
the content of thoughts in
favor of methods that attempt to alter the function of the
thoughts and not their content. More
specifically, they aim to change the individual’s relationship to
dysfunctional beliefs (i.e., the
586 Journal Of Clinical Psychology, June 2013
significance of having these beliefs), a process through which
cognitions are thought to become
“neutralized” and the distress related to them is reduced or
accepted.
Therapeutic change is considered to be brought about through
the modification of key pro-

cesses postulated to be at the root of psychopathology. One such
process is experiential avoid-
ance/psychological inflexibility. Experiential avoidance (EA)
refers to excessive negative evalua-
tions of unwanted thoughts, feelings, bodily sensations,
memories, or behavioral predispositions,
as well as an unwillingness to experience these private events,
and deliberate efforts to control
them or be rid of them (Hayes et al., 1999). EA is proposed to
represent a stronger contributor
to psychopathology than the content (e.g., intensity, frequency,
negative valence) of private psy-
chological and emotional experiences (Hayes et al., 1999). In
clinical and nonclinical samples,
it was found to be strongly correlated with measures of general
psychopathology (Hayes et al.,
2004) and specific measures of anxiety and depression (Forsyth,
Parker, & Finlay, 2003; Marx
& Sloan, 2005; Roemer, Salters, Raffa, & Orsillo, 2005).
Objectives of the Studies
The aim of the present research is to clarify the
interrelationships among key theoretical processes
of three forms of CBT (REBT, CT, and ACT) in regard to their
relative contributions to distress.
For REBT, we considered irrational beliefs and unconditional
self-acceptance as they are the core
cognitive processes in REBT (see David, Lynn, & Ellis, 2009).
For CT we chose dysfunctional
attitudes (cognitive distortions) as they are at the heart of
cognitive therapy (Beck, 1995). Finally,
for ACT, the key process considered was experiential
avoidance/psychological inflexibility, since
it is at the heart of ACT and one of the most investigated ACT
components (Hayes et al., 2004). To

our knowledge, associations between irrational
beliefs/unconditional self-acceptance (REBT),
dysfunctional cognitions (CT), experiential
avoidance/psychological inflexibility (ACT), and
emotional distress have not been examined within a single
study.
Our other objective involved determining the relative
contributions of the constructs to
psychological distress. We set to explore the possible
mediational models using these concepts,
using distress as an outcome, to test whether the effect of
classical CBT constructs on distress
was mediated by the third wave construct of experiential
avoidance or vice versa.
General Method
Overview
We investigated these relations in two types of samples: a
healthy one nonetheless vulnerable to
experiencing distress (Study 1) and a clinical sample (Study 2).
The study design, as well as the
procedure and the instruments used, were consistent across
studies.
Measures
Clinical diagnosis. We used the Structured Clinical Interview
for Diagnostic and Statisti-
cal Manual of Mental Disorders Fourth Edition Text Revision
(DSM-IV-TR) Axis I Disorders,
Patient Edition (SCID-I/P; First, Spitzer, Gibbon, & Williams,
2002). In Study 1 we applied
only the screening questionnaire to exclude participants with a

suspicion of psychopathology,
while in Study 2 we used the entire SCID to assess clinical
diagnostic status.
Irrational and rational beliefs. The Attitudes and Beliefs Scale 2
(ABS 2; DiGiuseppe,
Robin, Leaf, & Gormon, 1989) was devised as a measure of the
central constructs in REBT.
It comprised 72 items representing assertions with which the
person is asked to rate his/her
agreement on a 5-point Likert scale, ranging from 0 (strongly
disagree) to 4 (strongly agree). The
items denote beliefs an individual might hold about particular
situations and are formulated in
either irrational or rational terms. We computed both
irrationality and rationality scores. The
ABS 2 was adapted and validated on the Romanian population
(Macavei, 2002). Reliability was
assessed on a sample of 340 individuals and indicated good
internal consistency (Cronbach’s
alpha of 0.88 for the total scale). Factor analysis on the
Romanian ABS 2 supported the presence
of two distinct factors, corresponding to irrationality and
rationality (Fulop, 2007).
Unconditional self-acceptance. The Unconditional Self-
Acceptance Questionnaire
(USAQ; Chamberlain & Haaga, 2001) was developed based on
Albert Ellis’s theory of un-
conditional self acceptance, a central concept of REBT. The
person has to evaluate the degree

of agreement with 20 assertions on a 7-point Likert scale.
Higher scores indicate higher un-
conditional self-acceptance. The USAQ was adapted on the
Romanian population (Macavei,
2007). Reliability analysis on a sample of 437 individuals
indicated good internal consistency
(Cronbach’s alpha = 0.73). Validity analysis showed positive
associations between unconditional
self-acceptance and rational beliefs, and negative ones between
unconditional self-acceptance
and different types of dysfunctional beliefs, as well as distress.
Dysfunctional attitudes. The Dysfunctional Attitudes Scale A
(DAS-A; Weissman &
Beck, 1978) offers information regarding the person’s
dysfunctional attitudes, which function as
schemata through which the individual builds his/her view of
reality. It comprises 40 items for-
mulated as assertions to be rated on a 7-point Likert scale,
ranging from total agreement to total
disagreement. Even though this scale was initially developed to
measure cognitions relevant to
depression, subsequent studies showed it measured more general
cognitive vulnerabilities (Dyck,
1992). The DAS-A was adapted for the Romanian population
(Macavei, 2006). Reliability analy-
sis on a sample of 701 individuals indicated a value of
Cronbach’s alpha of 0.86. Validity analysis
showed that the scale correlated positively with other measures
of dysfunctional thinking, as
well as with negative emotions. Moreover, the DAS-A was able
to discriminate between subjects
with high and low levels of negative emotions.
Experiential avoidance/psychological inflexibility. The
Acceptance and Action Ques-

tionnaire (AAQ-II; Bond et al., 2011) is a revised form of the
AAQ (Hayes et al., 2004), which was
originally developed to provide an internally consistent measure
of the ACT treatment model
and behavioral effectiveness. The instrument comprises seven
items, representing statements
that the person evaluates in terms of how true they are for
him/her on a 7-point Likert scale.
High scores indicate high experiential avoidance (or high
psychological inflexibility). Factorial
analysis showed the AAQ-II is a one-dimensional measure that
assesses the key ACT construct
referred to, variously, as experiential avoidance or
psychological inflexibility. Confirmatory fac-
tor analysis indicated that it did so in a comparable manner
across very different samples. The
AAQ-II was translated into Romanian for the purpose of this
study (details of the procedure are
available upon request). It presented very good internal
consistency (Cronbach’s alpha = 0.88
for the sample in Study 1 and 0.90 for the clinical sample in
Study 2).
Emotional distress. The Profile of Emotional Distress/Profile of
Affective Distress
(PED/PAD; Opris & Macavei, 2005) is an instrument designed
to evaluate distress. It com-
prises 39 items that are adjectives describing emotions, both
negative and positive. The subject
is asked to rate the suitability of each item in assessing how
he/she has felt during the last
2 weeks, on a 5-point Likert scale. The global negative
emotions score was used in the current
studies as an index of distress. The scale was validated on the
Romanian population (Opris &
Macavei, 2007). The reliability analysis on a sample of 745

healthy volunteers indicated very
good internal consistency for the negative emotions scale
(Cronbach’s Alpha = 0.94). Validity
analysis revealed a two-factor structure, with a general distress
factor accounting for around
60% of the variance, and a second factor, named functional
distress, for around 28% of the
variance.
Procedure
Participants were asked for consent and then given the scales.
They were told the data would
be used for study purposes and they could receive a
personalized interpretation of the results
should they wish to.
Data Analysis
We applied correlational and mediational analysis. For
mediational analysis, we used the boot-
strapping procedure for assessing indirect effects (Preacher &
Hayes, 2008). We used the Preacher
and Hayes (2008) mediation script for SPSS for calculations.
We calculated effect sizes for the mediational models following
the procedure recommended
by Preacher and Kelley (2011), using the MBESS package
(Kelley & Lai, 2010). Given the
inherent difficulties of estimating effect sizes for mediation
procedures, the authors recommend
a standardized index called kappa-squared (i.e., κ2), which

represents the magnitude of the
indirect effect relative to the maximum possible indirect effect,
given the design of the study and
the distributional particularities of the variables considered.
Study 1
Research demonstrates that the period before an exam (Malouff
et al., 1992) is often a stressful
one, which may negatively affect emotional health. In Study 1
we explored the relationships
between the constructs in a nonclinical sample in such a period,
before moving to a clinical
sample in Study 2.
Method
One hundred and fifty-two student participants took part in the
study. The gender distribution
was 22.4% males (n = 34) and 77.6% females (n = 118). Ages
ranged from 17 to 25 years, with
a mean age of 21.71 (standard deviation [SD] = 1.33). None of
the subjects had had any prior
experience with any of the forms of therapy taken into account.
Absence of psychopathology was
assessed with the screening questionnaire of the SCID-I/P
(First, Spitzer, Gibbon, & Williams,
2002). One hundred seventy subjects were screened, 18 of
which were not included in the study
due to suspicion of psychopathology. Subjects were tested right
before their exam period.
Results and Discussions
Descriptive data. Descriptive data for the main variables are
presented in Table 1. The

mean score for distress, reported on the PED/PAD, qualifies the
sample as having a high level of
negative emotions, according to comparisons with Romanian
norms (Opris & Macavei, 2007).
Correlational analysis. The association between the cognitive
variables from each therapy
approach considered and their associations with distress are
presented in Table 2.
The results from the correlational analysis showed a significant
and high positive correla-
tion between irrational beliefs and dysfunctional attitudes, as
well as a significant and medium
Table 1
Means, Standard Deviations (SD), Minimum (Min) and
Maximum (Max) Values for the Main
Variables in Study 1
N Min Max Mean SD
USAQ Unconditional self-acceptance 151 42 120 80.08 13.27
AAQ-II Experiential avoidance 152 7 46 21.21 8.51
DAS-A Dysfunctional attitudes 149 44 214 124.01 29.65
ABS 2 Global Irrationality 152 4 216 99.14 42.83
ABS 2 Rationality 152 36 163 102.05 22.38
PED/PAD Distress 150 32 127 61.93 22.73
Note. USAQ = Unconditional Self-Acceptance Questionnaire;
AAQ-II = Acceptance and Action Ques-
tionnaire II; DAS-A = Dysfunctional Attitudes Scale A; ABS 2
= The Attitudes and Beliefs Scale 2; PED/
PAD = Profile of Emotional Distress/Profile of Affective
Distress.

Table 2
Correlations Between the Cognitive and Subjective/Emotional
Cognitive variables 1 2 3 4 5 6
1. USAQ Unconditional self-acceptance —
2. AAQ-II Experiential avoidance −.55∗ —
3. DAS-A Dysfunctional attitudes −.61∗ .53∗ —
4. ABS 2 Global Irrationality −.38∗ .40∗ .60∗ —
5. ABS 2 Rationality .19 −.21 −.40∗ −.88∗ —
Subjective-emotional variables
6. PED/PAD Distress −.42∗ .60∗ .32∗ .24∗ −.14 —
tionnaire; DAS-A = Dysfunctional Attitudes Scale A; ABS 2 =
The Attitudes and Beliefs Scale 2; PED/
Distress.
∗ p < .003 Bonferroni corrected for multiple comparisons.
negative correlation between irrational beliefs and
unconditional self-acceptance. Irrational be-
liefs and dysfunctional attitudes are both core beliefs, organized
as evaluative and, respectively,
descriptive/inferential schemas, and thus strongly related to
each other. One theoretical pos-
sibility is that the core irrational beliefs prime the generation of
dysfunctional cognitions in
negative situations and then both generate more specific
evaluative and descriptive/inferential

beliefs in the form of automatic thoughts (David et al., 2009).
The small correlation between rational beliefs and unconditional
self-acceptance may indicate
they represent different aspects of adaptive thinking.
Unconditional self-acceptance denotes the
notion that “the individual fully and unconditionally accepts
himself whether or not he be-
haves intelligently, correctly, or competently and whether or not
other people approve, respect,
or love him” (Ellis, 1977, p. 101). As such, it may represent a
different thinking process than
other types of rational/functional beliefs, aiming at more
radical, profound modifications of
an individual’s life philosophy (Ellis, 1994). Experiential
avoidance/psychological inflexibility
displayed medium to high positive correlations with cognitive
constructs related to dysfunc-
tional thinking (irrationality, dysfunctional attitudes), pointing
to the existence of a degree of
overlap.
Also experiential avoidance had a medium to high negative
correlation (r = −0.55) with
unconditional self-acceptance, which again could imply they
deal with related, yet distinct,
approaches to acceptance. The REBT concept of unconditional
self-acceptance might be related
to the ACT concept of acceptance (the opposite of experiential
avoidance, see Bond et al.,
2011). In this sense we could speculate that the unconditional
regard for oneself promoted by
REBT might also incorporate an acceptance of self-critical
cognitions or of painful experiences,
promoted by ACT. An intriguing association was the negative,
but small and nonsignificant,

correlation between experiential avoidance and rational beliefs,
supporting the idea the two
represent distinct constructs.
The associations between these constructs and distress were
consistent with the underlying
theories. Irrationality had medium positive correlation with
distress (see David et al., 2005).
Dysfunctional attitudes also had medium positive correlations to
distress (see de Graaf et
al., 2009). As expected from the ACT literature (e.g., Hayes et
al., 2004), experiential avoid-
ance/psychological inflexibility bore high positive associations
with distress.
Mediation analysis. We used bootstrapping tests with 5,000 re-
samples and reported
a bias corrected and accelerated confidence interval (Preacher &
Hayes, 2008). Mediation is
considered to have taken place when the confidence interval for
the estimation of the indirect
effect does not contain 0. We alternatively tested all possible
meditational models, using distress
as the outcome (experiential avoidance as a mediator and the
classic CBT constructs as respective
predictors; experiential avoidance as predictor and each of the
other, classic CBT constructs as
potential mediators).
Figure 1. Simple mediation diagrams for Study 1. Values are
path coefficients representing standardized
regression weights and standard errors (in parentheses). The c

path coefficient refers to the total effect of the
independent variable (IV) on the dependent variable (DV). The
c-prime path coefficient refers to the direct
effect of the IV on the DV.
The results indicated that experiential avoidance/psychological
inflexibility acted as a media-
tor in the relationship between global irrationality and
emotional distress, indirect effect = .13,
standard error (SE) = .03, 95% confidence interval (CI; bias
corrected and accelerated) = .08 to
.20. Experiential avoidance/psychological inflexibility also
mediated the relationship between
unconditional self-acceptance and emotional distress, indirect
effect = −.52, SE = .10, 95%
CI (bias corrected and accelerated) = –.74 to −.34, and between
dysfunctional attitudes and
emotional distress, indirect effect = .25, SE = .05, 95% CI (bias
corrected and accelerated) =
.17 to .36. For each of the alternative models, the confidence
intervals of the indirect effects
contained zero, indicating the absence of mediation. Figure 1
depicts the significant mediation
models.
Effect sizes were calculated for all significant mediation
models. In the first one, with experien-
tial avoidance mediating the relationship between global
irrationality and emotional distress, κ2
took the value of .25, 95% CI (bias corrected) = .14 to .35. In
the second model, where experien-

tial avoidance mediated the relationship between unconditional
self-acceptance and emotional
distress, κ2 was .28, 95% CI (bias corrected) = .19 to .37. In the
case of experiential avoidance
mediating the relationship between dysfunctional attitudes and
emotional distress, κ2 was .31,
95% CI (bias corrected) = .22 to .40.
We underscore that irrational beliefs and dysfunctional
cognitions are conceptualized as core
beliefs, vulnerability factors, coded as underlying schemata
(Beck, 1995; Ellis, 1994); hence, they
are more general and not easily experienced directly. Moreover,
by interaction with specific
activating events, they generate automatic thoughts that are
experienced consciously and are
associated with dysfunctional feelings and behaviors. According
to ACT theory, experiential
avoidance might include the lack of willingness to experience
(i.e., rather than alter the content
or frequency of) these automatic thoughts (i.e., unwanted
private events – in ACT terms; Hayes
et al., 1999). Thus, if these constructs are related to each other,
the effect of irrational beliefs and
dysfunctional cognitions on distress could be mediated on one
hand by experiential avoidance,
and on the other hand by automatic thoughts. Regarding
experiential avoidance, our study
provides support for this prediction. Other studies sustain the
mediating role of automatic
thoughts in the relationship between deeper level cognitive
constructs (e.g., irrational beliefs)
and distress (Szentagotai & Freeman, 2007). However, there are
no studies investigating all of
these constructs in the same research design.

Consequentially, some interesting conjectures emerged after
Study 1, regarding the rela-
tionship between experiential avoidance and automatic thoughts
as mediators between more
general, deeper, schema-type constructs and distress. One
theoretical possibility would be that
irrational beliefs and/or dysfunctional cognitions represent
underlying cognitive vulnerabilities
that in negative situations generate automatic thoughts (specific
cognitions, evaluative and/or
descriptive/inferential, related to the activating events), which
are then experientially avoided,
generating distress. The other would be that irrational beliefs
and/or dysfunctional cognitions,
as underlying cognitive vulnerability factors, prompt the
response of experiential avoidance,
which in turn activates automatic thoughts by a mechanism
similar to the paradoxical rebound
effect of suppression (i.e., the “white bear” effect–Wegner,
Schneider, Carter, & White, 1987).
Study 2
In Study 2, we aimed to see whether the mediation models
supported in Study 1 were valid in
the case of a clinical sample. We used the same measures of
beliefs and distress so as to make
the results comparable to the ones for the healthy sample. We
also wanted to check which of
the two theoretical predictions regarding the potential role of
automatic thoughts, advanced
consequently to Study 1, better described the relationships
between the constructs considered.
Thus, we also measured automatic thoughts as a potential
mediator in the relationship between
more profound cognitive structures (e.g., irrational beliefs),

experiential avoidance and distress.
Method
Twenty-eight participants (26 females, 2 males) diagnosed with
generalized anxiety disorder
(GAD) took part in this study. Ages ranged from 21 to 50 years,
with a mean age of 26.67
(SD = 6.29). None of the subjects had had any prior experience
with any of the forms of
therapy taken into account. Subjects were recruited from an
ongoing randomized clinical trial
comparing various forms of CBT for GAD. All participants
were diagnosed with GAD after
having been evaluated with SCID-I/P module for anxiety
disorders (First, Spitzer, Gibbon, &
Williams, 2002). The procedure used was the same as in Study
1, with the addition of a measure
of automatic thoughts. Questionnaires were completed at
baseline before the participants were
randomized in any of the treatment groups.
Automatic thoughts were measured with the Automatic
Thoughts Questionnaire (ATQ; Hol-
lon & Kendall, 1980). This instrument comprises 15 statements
that represent dysfunctional
self-related automatic thoughts. The subject has to rate them in
terms of frequency of occurrence
on a 5-point Likert scale, ranging from 1 (never) to 5 (almost
always). The ATQ was adapted on
the Romanian population (Moldovan, 2007), on a sample of 240

individuals, showing excellent
reliability (Cronbach’s alpha = .92). Validity analysis indicated
the scale correlated positively
with other measures of dysfunctional thinking (irrational
beliefs, dysfunctional attitudes) and
negatively with unconditional self-acceptance and self-esteem.
We employed the same data analysis procedure as in Study 1
(correlational and mediation
analysis), but additionally we tested multiple step mediation.
We applied the Hayes, Preacher,
and Myers (2011) multiple step multiple mediation procedure in
which mediators are allowed
to influence each other, implemented in the MEDTHREE script
for SPSS. We reported bias
corrected and accelerated confidence intervals for 5000
bootstrap samples.
Results and Discussions
Descriptive data. Means and standard deviations, as well as
minimum and maximum
values for the main variables included in the study, are
presented in Table 3. Predictably, the
clinical sample scored high on measures of emotional distress,
both compared with the normative
values of the PED/PAD scale (Opris & Macavei, 2007), as well
as to the sample from Study 1.
Correlational analysis. The association among variables from
each therapy approach
considered (REBT, CT, ACT) and their associations with
distress are presented in Table 4.
Table 3
Means, Standard Deviations (SD), Minimum (Min) and

Maximum (Max) Values for the Main
N Min Max Mean SD
USAQ Unconditional self-acceptance 28 45 109 70.14 16.97
AAQ-II Experiential avoidance 28 13 47 33.25 8.81
DAS-A Dysfunctional attitudes 27 106 231 151.67 31.17
ABS 2 Global Irrationality 28 29 234 121.75 52.81
ABS 2 Rationality 28 34 130 90.91 25.79
PED/PAD Distress 28 26 132 86.57 28.31
tionnaire II; DAS-A = Dysfunctional Attitudes Scale A; ABS 2
= The Attitudes and Beliefs Scale 2; PED/
Distress.
Table 4
Correlations Between the Cognitive and Subjective/Emotional
Cognitive variables 1 2 3 4 5 6 7
1. USAQ Unconditional self-acceptance —
2. AAQ-II Experiential avoidance −.62∗ —
3. DAS-A Dysfunctional attitudes −.67∗ .47∗ —
4. ABS 2 Global Irrationality −.77∗ .61∗ .80∗ —
5. ABS 2 Rationality .69∗ − .48 −.74∗ −.95∗ —
6. ATQ Automatic thoughts −.38 .74* .57∗ .58∗ −56∗ —
Subjective-emotional variables
7. PED/PAD Distress −.59∗ .75∗ .58∗ .75∗ −.70∗ .79∗ —

tionnaire; DAS-A = Dysfunctional Attitudes Scale A; ABS 2 =
The Attitudes and Beliefs Scale 2; ATQ-
Automatic Thoughts Questionnaire; PED/PAD = Profile of
Emotional Distress/Profile of Affective Dis-
tress.
∗ p < .05 Holm-Bonferroni corrected for multiple comparisons.
The correlation pattern was similar to the one obtained in Study
1. However the correlations
were higher than those for the sample in Study 1. Functional,
protective constructs such as
rationality or unconditional self-acceptance had medium to high
degrees of correlation,
higher than in Study 1. Their associations with the ACT
construct of experiential avoid-
ance/psychological inflexibility were also medium to high
(albeit not significant for rationality).
Automatic thoughts were, as expected from the literature,
highly correlated with distress. They
displayed medium correlations with the more broad, core
cognitive constructs (irrationality, dys-
functional attitudes), indicating they represent different, but
related constructs. We also noted
there was a high positive correlation with experiential
avoidance.
We believe these results might suggest that vulnerability factors
such as irrational beliefs,
dysfunctional schema, automatic thoughts, and experiential
avoidance are more influential and
effective in generating emotional distress in the case of a
clinical sample.

Simple mediation analysis. The results indicated experiential
avoidance/psychological
inflexibility acted as a mediator in the relationship between
global irrationality and emotional
distress, indirect effect = .15, SE = .06, 95% CI (bias corrected
and accelerated) = .06 to
.30. Experiential avoidance/psychological inflexibility also
mediated the relationship between
unconditional self-acceptance and emotional distress, indirect
effect = −.65, SE = .23, 95% CI
(bias corrected and accelerated) = – 1.21 to −.30, as well as
between dysfunctional attitudes
and emotional distress, indirect effect = .26, SE = .11, 95% CI
(bias corrected and accelerated)
= .09 to .53. The converse models were again nonsignificant
(the confidence interval of the
indirect effect contained zero). A graphic representation of the
mediation models is presented in
Figure 2.
Effect sizes were calculated for all three mediation models. In
the first one, with experiential
avoidance mediating the relationship between global
irrationality and emotional distress, κ2
took the value of .34, 95% CI (bias corrected) = .16 to .53. In
the second model, where experien-
tial avoidance mediated the relationship between unconditional
self-acceptance and emotional
distress, κ2 was .39, 95% CI (bias corrected) = .17 to .59. In the
case of experiential avoidance
mediating the relationship between dysfunctional attitudes and
emotional distress, κ2 = .32, 95%
CI (bias corrected) = .10 to .51.

The results were therefore consistent with those of Study 1,
indicating that the effects of
more general, schema-like cognitive variables (irrationality,
unconditional self-acceptance, dys-
functional attitudes) on emotional distress were carried out
through the mediation of the more
circumscribed construct of experiential avoidance.
Multiple step mediation analysis. We also tested two alternative
multiple mediation
models, corresponding to the two possible paths we anticipated
theoretically: with automatic
thoughts as mediator 1 and experiential avoidance as mediator
2, and, respectively, with ex-
periential avoidance as mediator 1 and automatic thoughts as
mediator 2. As predictors we
consecutively used each of the schema-type constructs, while as
outcome we used distress.
Our results showed significant mediation in the cases in which
experiential avoidance played
the role of mediator 1 and automatic thoughts the role of
mediator 2: with irrationality as the
predictor, indirect effect = .08, SE = .05, 95% CI (bias
corrected and accelerated) = .01 to .22;
with unconditional self-acceptance as a predictor, indirect effect
= −.40, SE = .25, 95% CI (bias
corrected and accelerated) = −1.08 to −.09; and with
dysfunctional attitudes as the predictor,
indirect effect = .11, SE = .08, 95% CI (bias corrected and
accelerated) = .002 to .31. For
each of the alternative models (automatic thoughts as mediator
1 and experiential avoidance as
mediator 2), the confidence intervals of the indirect effect
contained zero, indicating the absence
of mediation. A graphic representation of these models is

presented in Figure 3.
Summary and Concluding Discussion
The first major conclusion of our research was that these core
constructs, central for each of
the therapies considered, shared a degree of overlap. Their
associations were medium to high,
which could mean they measure similar, related, but still
distinct, processes. REBT unconditional
Figure 2. Simple mediation diagrams for Study 2. Values are
path coefficients representing standardized
regression weights and standard errors (in parentheses). The c
path coefficient refers to the total effect of the
independent variable (IV) on the dependent variable (DV). The
c-prime path coefficient refers to the direct
effect of the IV on the DV.
self-acceptance shared significant variance with ACT
acceptance (understood as the opposite
process of experiential avoidance; see Bond et al., 2011 for
details), but each maintained a
standalone, distinct part. Future studies could further clarify the
nature of these associations.
For instance, one might speculate that REBT acceptance of the
person as a whole also includes
ACT acceptance of unwanted thoughts or experiences. REBT’s
preferential, rational formulation
of desires or goals (e.g., “I would like to get a good result and
do my best to get it, but I accept
that it might not happen no matter how hard I try”) might

intersect with core acceptance
components developed in ACT. Schema-type constructs like
irrational beliefs and dysfunctional
attitudes were significantly associated with experiential
avoidance, but a non-negligible part of
each of them remained distinct. The observed overlap may be
because of the characteristics of
rigidity and inflexibility expressed by all three constructs.
The second major conclusion was that experiential
avoidance/psychological inflexibility me-
diated the relationship between the cognitive constructs (e.g.,
irrationality, unconditional self-
acceptance, dysfunctional attitudes) and distress. The effect
held for both the student sample
Figure 3. Multiple step mediation diagrams for Study 2. Values
are path coefficients representing stan-
dardized regression weights and standard errors (in
parentheses). The c path coefficient refers to the total
effect of the independent variable (IV) on the dependent
variable (DV). The c-prime path coefficient refers
to the direct effect of the IV on the DV.
in Study 1, as well as for the clinical sample in Study 2. Our
results are consistent with the
mediation analyses conducted by Kashdan, Barrios, Forsyth, and
Steger (2006), in which rigid,
inflexible coping mechanisms affected distress and adaptation
via experiential avoidance. While
we looked at dysfunctional thinking patterns and not coping or
emotion regulation strategies,

it is possible that the rigid, inflexible character of these
different variables is responsible for
triggering avoidant response tendencies that in turn are
responsible for sustaining distress.
An interesting key result, which emerged in the multiple step
mediation analysis of Study 2,
was that the effect of the more general, schema-type constructs
on distress was carried out by
acting upon experiential avoidance, which in turn primed
automatic thoughts that were the most
proximal to distress. In an integrated CBT theory we can argue
that during an activating event
deeper, schema type constructs activate experiential avoidance
which in turn primes automatic
thoughts presumably by a mechanism similar to Wegner et al.
(1987) “white bear effect” (i.e.,
avoided thoughts return with more frequency). However,
because of our limited sample size, we
recommend the testing of these multiple mediation models on
larger samples.
We used a robust method for testing mediation–bootstrapping–
which has the advantage of
being independent from sample sizes and not assuming a normal
distribution of the indirect
effects (Preacher & Hayes, 2008). The values for our effect
sizes (around .30) indicated we
managed to show a consistent part of the maximum indirect
effect that could have been attained
given the design and distribution characteristics. Preacher and
Kelley (2011) also gave some

tentative benchmark values for kappa-squared, warning they are
to be interpreted cautiously.
The values proposed are same ones as for Cohen’s r2–small,
medium and large effect sizes
correspond to values of 0.01, 0.09, and 0.25, respectively
(Cohen, 1988, pp. 79–81). In our
case, all of the confidence intervals for the effect sizes included
0.25, indicating large effect
sizes.
Theoretically, from a classical CBT standpoint, these results
seem to reinforce the notion
that irrational beliefs and/or dysfunctional cognitions are
underlying cognitive vulnerability
factors that in negative situations activate experiential
avoidance, which in turn primes automatic
thoughts, possibly by a mechanism similar to Wegner et al.’s
(1987) white bear effect (i.e., avoided
thoughts return with more frequency, generating distress).
However, our results can also be
integrated in a third wave CBT (i.e., ACT) perspective. It could
be that irrational beliefs and
dysfunctional cognitions, by being rigid and inflexible,
represent barriers in the pursuit of valued
goals and, thus, foster experiential avoidance/psychological
inflexibility.
The cross-sectional nature of our study does not warrant us to
draw conclusions about
the effects that changes in these constructs may have on
changes in distress. An interesting
conjecture could be that a change only in experiential avoidance
and/or automatic thoughts
might momentarily reduce distress, but leave the client with
deeper, schema-type latent cognitive
vulnerabilities (e.g., irrational beliefs, dysfunctional

cognitions), which might become activated
in future situations and foster the cycle all over again. Future
randomized controlled trials with
follow-up analyses could test this hypothesis. In this direction,
a recent study (Kuyken et al.,
2010) showed that for participants with recurrent depression
who received mindfulness-based
cognitive therapy (MBCT), cognitive reactivity posttreatment
was not related with depressive
symptoms at 15 months follow-up, but that the relationship was
present in the medication group.
While this result seems to indicate that MBCT did indeed
change the very relationship between
dysfunctional thoughts and the emotional outcomes, we note
that another study (Manicavasagar,
Perich, & Parker, 2012) looking at cognitive predictors of
change (rumination) did not report
differences between MBCT and a classical CBT intervention.
Our research has several limitations. The most important is the
very nature of the study,
which used a cross-sectional design. Cross-sectional studies
have previously been used to test
relationships between constructs in psychotherapeutic models,
both in general and for specific
disorders. Nonetheless, because all measures were taken at the
same time point, we cannot
conclude that the proposed mediators do indeed account for
changes in the dependent variable
(distress). Future studies should address this limitation by
measuring hypothesized mediators
prior to assessing outcome.
Another limitation is that while classical CBT was represented
by more core constructs,
measuring different aspects on dysfunctional thinking, third

wave CBT was represented by just
one. Future studies could include more processes coming from
ACT and third wave approaches
in relationship to more classical CBT constructs and with
distress to test for complex mediation
models. Last, procedural limitations should also be noted. While
the measures for constructs
in classical CBT are among the most widely used and
psychometrically sound (Bridges &
Harnish, 2010) and have been adapted on the Romanian
population, the measure for experiential
avoidance/psychological inflexibility (AAQ-II) had not been
previously used. However we did
report good psychometric properties on both samples used in
our studies. Also it is possible that
the screening questionnaire of the SCID used to rule out
participants with psychopathology in
Study 1 might have had some false negatives.
The study should be replicated on other samples of participants,
especially on various clinical
samples. Moreover, research efforts should be devoted to
formulating a CBT paradigm that
would explain and integrate these findings.
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Oxytocin increases trust in humans
Michael Kosfeld
1*, Markus Heinrichs2*, Paul J. Zak3, Urs Fischbacher1 &
Ernst Fehr1,4
Trust pervades human societies1,2. Trust is indispensable in
friend-
ship, love, families and organizations, and plays a key role in
economic exchange and politics3. In the absence of trust among
trading partners, market transactions break down. In the absence
of trust in a country’s institutions and leaders, political
legitimacy
breaks down. Much recent evidence indicates that trust contrib-
utes to economic, political and social success4,5. Little is
known,
however, about the biological basis of trust among humans.
Here
we show that intranasal administration of oxytocin, a neuro-
peptide that plays a key role in social attachment and affiliation
in non-human mammals6–8, causes a substantial increase in
trust
among humans, thereby greatly increasing the benefits from
social
interactions. We also show that the effect of oxytocin on trust is
not due to a general increase in the readiness to bear risks. On
the
contrary, oxytocin specifically affects an individual’s
willingness
to accept social risks arising through interpersonal interactions.

These results concur with animal research suggesting an
essential
role for oxytocin as a biological basis of prosocial approach
behaviour.
In non-human mammals, the neuropeptide oxytocin has a central
role in general behavioural regulation, particularly in positive
social
interactions. Aside from its well-known physiological functions
in
milk letdown and during labour, oxytocin receptors are
distributed
in various brain regions associated with behaviour9,10,
including pair
bonding, maternal care, sexual behaviour, and the ability to
form
normal social attachments6–8,11–15. Thus, oxytocin seems to
permit
animals to overcome their natural avoidance of proximity and
thereby facilitates approach behaviour. Given that oxytocin is
believed to promote social attachment and affiliation in non-
human mammals, we hypothesized that oxytocin might also pro-
mote prosocial approach behaviours — such as trust — in
humans.
Recent research has shown that neuropeptides cross the blood-
brain
barrier after intranasal administration16, providing a useful
method
for studying the central nervous system effects of oxytocin in
humans17,18. We used a double-blind study design to compare
trusting behaviour in a group of subjects that received a single
dose
of intranasal oxytocin with that of subjects in a control group
that
received placebo.

We analysed the effect of exogenously administered oxytocin on
individuals’ decisions in a trust game with real monetary
stakes19–22.
In this trust game, two subjects interacting anonymously play
either
the role of an investor or a trustee (Fig. 1). First, the investor
has the
option of choosing a costly trusting action by giving money to
the
trustee. If the investor transfers money, the total amount
available for
distribution between the two players increases but, initially, the
trustee reaps the whole increase. The trustee is then informed
about the investor’s transfer and can honour the investor’s trust
by
sharing the monetary increase generated by the investor’s
transfer.
Thus, if the investor gives money to the trustee and the latter
shares
the proceeds of the transfer, both players end up with a higher
monetary payoff. However, the trustee also has the option of
violating the investor’s trust. As sharing the proceeds is costly
for
the trustee, a selfish trustee will never honour the investor’s
trust
because the investor and the trustee interact only once during
the
experiment.
The investor is therefore caught in a dilemma: if he trusts and
the
trustee shares, the investor increases his payoff, but he is also
subject
to the risk that the trustee will abuse this trust. In the latter
case, the

investor is worse off than if he had not trusted at all and, adding
insult
to injury, the trustee has an unfair payoff advantage relative to
the
investor. Substantial evidence exists to show that humans are
averse
to such risks22–24. Moreover, the aversion of investors to abuse
of trust
seems to have an important role across different human cultures
and
social groups in the context of our game22,25. The investors
have to
overcome their aversion against these risks in order to trust,
allowing
us to address the question of whether oxytocin modulates this
trusting behaviour in humans.
LETTERS
Figure 1 | The trust game. Both subjects receive an initial
endowment of 12
monetary units (MU). The investor can send 0, 4, 8 or 12 MU to
the trustee.
The experimenter triples each MU the investor transfers. After
the investor’s
decision is made, the trustee is informed about the investor’s
transfer. Then
the trustee has the option of sending any amount between zero
and his total
amount available back to the investor. For example, if the
investor has sent
12 MU, the trustee possesses 48 MU (12 MU own endowment þ
36 MU

tripled transfer) and can, therefore choose any back transfer
from 0 to
48 MUs. The experimenter does not triple the back transfer. The
investor’s
final payoff corresponds to the initial endowment minus the
transfer to the
trustee, plus the back transfer from the trustee. The trustee’s
final payoff is
given by his initial endowment plus the tripled transfer of the
investor,
minus the back transfer to the investor. At the end of the
experiment, the
earned MU are exchanged into real money according to a
publicly
announced exchange rate (see Methods). Each subject made four
decisions
in the same player role while paired with four different,
randomly selected
interaction partners.
1
University of Zurich, Institute for Empirical Research in
Economics, Blumlisalpstrasse 10, CH-8006 Zurich, Switzerland.
2
University of Zurich, Department of Clinical Psychology
and Psychotherapy, Zurichbergstrasse 43, CH-8044 Zurich,
Switzerland.
3
Center for Neuroeconomics Studies, Claremont Graduate
University, Claremont, California 91711-6165,
USA.
4
Collegium Helveticum, Schmelzbergstrasse 25, CH-8092

Zurich, Switzerland.
*These authors contributed equally to this work.
Vol 435|2 June 2005|doi:10.1038/nature03701
673
© 2005 Nature Publishing Group
Our hypothesis that oxytocin increases the trusting behaviour of
investors implies that the investors in the oxytocin group (n ¼
29)
will show higher money transfers than those in the placebo
group
(n ¼ 29). In fact, our data show that oxytocin increases
investors’
trust considerably. Out of the 29 subjects, 13 (45%) in the
oxytocin
group showed the maximal trust level, whereas only 6 of the 29
subjects (21%) in the placebo group showed maximal trust (Fig.
2a).
In contrast, only 21% of the subjects in the oxytocin group had
a trust
level below 8 monetary units (MU), but 45% of the subjects in
the
control group showed such low levels of trust. These
differences in
the distribution of trust result in higher average and median
trust
levels for subjects given oxytocin (Table 1). The investors’
average
transfer is 17% higher in the oxytocin group (Mann-Whitney U-

test;
z ¼ 21.897, P ¼ 0.029, one-sided), and the median transfer in
the
oxytocin group is 10 MU, compared to a median of only 8 MU
for
subjects in the placebo group.
In the trust game, the risk on the part of the investor’s is due to
the
uncertainty of the trustee’s behaviour — that is, a social
interaction
with a specific trustee constitutes the risk. This raises the
question of
whether oxytocin helps humans to overcome a general aversion
against risks or whether oxytocin specifically affects trusting
beha-
viour in social interactions. In order to answer this question, we
conducted a risk experiment in which the investor faced the
same
choices as in the trust game but in which a random mechanism,
not
the trustee’s decision, determined the investor’s risk. The
random
mechanism in the risk experiment replicated the trustees’
decisions in
the trust experiment. Therefore, the investors faced exactly the
same
risk as in the trust experiment (see Methods); however, their
transfer
decisions were not embedded in a social interaction because
there
were no trustees in the risk experiment.
In this risk experiment, the investors’ behaviour does not differ
between the oxytocin and the placebo groups (Table 1 and Fig.

2b).
The median transfer is 8 MU and the average transfer is 7.5 MU
in
both groups (Mann-Whitney U-test; z ¼ 0.022, P ¼ 0.983; two-
sided test, n ¼ 31 in oxytocin group, n ¼ 30 in placebo group).
Moreover, there is no significant difference in a comparison of
the
placebo group in the trust experiment with the oxytocin group
and
the placebo group in the risk experiment (Kruskal-Wallis test;
x
2
¼ 0.533, d.f. ¼ 2, P ¼ 0.766), with identical median transfers
across groups (Table 1). However, if we add the oxytocin group
in
the trust experiment to these three samples, significant
differences
are observed (Kruskal-Wallis test; x2 ¼ 8.610, d.f. ¼ 3, P ¼
0.035),
indicating that only the investors in the oxytocin group of the
trust
experiment behave differently. Thus, oxytocin increases the
investors’
transfer levels in the trust experiment but not in the risk
experiment.
This finding is illustrated by a comparison of Figs 2a and b,
which
show that only 10% of the subjects with oxytocin choose the
maximal
transfer level in the risk experiment, whereas 45% choose the
maximal level in the trust experiment. Therefore, the
differences
between the oxytocin group in the trust experiment and the
oxytocin

group in the risk experiment are highly significant (Mann-
Whitney
U-test; z ¼ 22.563, P ¼ 0.010, two-sided), suggesting that
oxytocin
specifically affects trust in interpersonal interactions.
The risk experiment constitutes a powerful control for the
effects
of oxytocin on trusting behaviour because everything is kept
con-
stant relative to the trust experiment, except that the investors’
risk in
the risk experiment is not generated through a social
interaction.
Specifically, all the indirect effects of oxytocin on the state of a
subject, such as possible effects on mood or calmness, would be
present in both the trust and the risk experiment. Therefore,
these
potential indirect effects of oxytocin cannot be responsible for
the
effect of oxytocin on trusting behaviour. Moreover, in order to
provide an additional control for non-specific effects that might
be
associated with oxytocin administration, we explicitly measured
mood and calmness before substance administration and 50 min
after administration (but before subjects played the trust or the
risk
game). We used a questionnaire suitable for repeated measures
within short periods of time, one that is widely used in
neuropharma-
cological studies in humans26 and correlates with physiological
measures17. There were no statistical differences in the levels
of
mood and calmness before and after the administration of
oxytocin
in either the trust or the risk experiment. (Trust experiment:

z ¼ 21.541, P ¼ 0.123 for calmness; z ¼ 1.452, P ¼ 0.146 for
mood; n ¼ 29. Risk experiment: z ¼ 0.620, P ¼ 0.535 for
calmness;
z ¼ 20.841, P ¼ 0.400 for mood; n ¼ 31; two-sided Wilcoxon
signed rank tests.) This provides further support for our
conclusion
Figure 2 | Transfers in the trust and the risk experiment. Each
observation
represents the average transfer amount (in MU) over four
transfer decisions
per investor. a, Relative frequency of investors’ average
transfers in oxytocin
(filled bars) and placebo (open bars) groups in the trust
experiment
(n ¼ 58). Subjects given oxytocin show significantly higher
transfer levels.
b, Relative frequency of investors’ average transfers in oxytocin
(filled bars)
and placebo (open bars) groups in the risk experiment (n ¼ 61).
Subjects in
the oxytocin and the placebo group show statistically identical
transfer
levels.
Table 1 | Median and average transfer behaviour of investors
Trust experiment Risk experiment
Oxytocin group Placebo group Oxytocin group Placebo group
Mean average transfer (MU) 9.6 8.1 7.5 7.5
Median average transfer (MU) 10 8 8 8
Standard deviation of transfers (MU) 2.8 3.1 3.3 3.4

Number of observations 29 29 31 30
LETTERS NATURE|Vol 435|2 June 2005
674
that the effect of oxytocin on human trust is not caused by non-
specific, psychotropic effects of oxytocin.
What mechanisms might be involved in generating the effect of
oxytocin on trusting behaviour? One possibility is that oxytocin
causes a general increase in prosocial inclinations. This implies
that
oxytocin should affect not only the prosocial behaviour of the
investors but also that of the trustees. We would therefore
predict
that those trustees who are given oxytocin should make higher
back
transfers at any given level than the trustees who received
placebo.
However, trustees given oxytocin do not show more trustworthy
behaviour (Fig. 3). At every positive transfer level (4, 8 or 12
MU),
their back transfers are statistically indistinguishable from those
of
placebo trustees (Mann Whitney U-tests; P . 0.243, two-sided
tests
for each positive transfer level). Thus, oxytocin does not
increase
the general inclination to behave prosocially. Rather, oxytocin
specifically affects the trusting behaviour of investors.

We hypothesize that the differing effect of oxytocin on the
behaviour of investors and trustees is related to the fact that
investors
and trustees face rather different situations. Specifically,
investors
have to make the first step; they have to ‘approach’ the trustee
by
transferring money. In contrast, the trustees can condition their
behaviour on the basis of the investors’ actions. Thus, the
psychology
of trust is important for investors, whereas the psychology of
strong
reciprocity27 is relevant for trustees. The fact that oxytocin
affects
subjects’ approach or trust behaviour, but not their degree of
reciprocity, is in agreement with animal studies. There is
substantial
evidence that oxytocin promotes prosocial approach behaviour
by
inhibiting defensive behaviours6,13, but there is no evidence
that
oxytocin affects reciprocity in animals.
A second mechanism behind the effect of oxytocin on trust
could
be based on subjects’ beliefs. Oxytocin might render subjects
more
optimistic about the likelihood of a good outcome. In order to
address this question, we measured the investor’s subjective
expec-
tation about the trustee’s back transfer after every transfer
decision.
A Mann-Whitney U-test indicates that these expectations do not
differ significantly between oxytocin and placebo groups at
every

feasible positive transfer level (P . 0.357, two-sided tests at
transfer
levels of 4, 8 or 12 MU). Thus, the investors given oxytocin
show
more trusting behaviour but do not hold significantly different
beliefs about the trustworthiness of others. Moreover, oxytocin
does not affect investors’ beliefs about the likelihood of a good
outcome in the risk experiment (P . 0.128, two-sided Mann
Whitney U-tests for transfer levels of 4, 8 or 12 MU).
Finally, there is the possibility that oxytocin helps subjects to
overcome their betrayal aversion in social interactions. This
expla-
nation is consistent with the differing effects of oxytocin across
the
trust and the risk experiments, and is further supported by the
fact
that investors faced a considerable betrayal risk. An increase in
the
transfer level from 4 or 8 MU to 12 MU decreased the investor’s
average payoff slightly, whereas it increased the objective risk
of very
low back transfers by the trustee. However, betrayal aversion
alone
cannot explain why investors given oxytocin make higher
transfers in
the trust experiment compared with the risk experiment, because
betrayal is impossible in the risk experiment. The higher
transfers in
the trust experiment can be reconciled with betrayal aversion if
one
acknowledges that investors’ behaviour in the trust experiment
is also
likely to be driven by the motive to increase the available
amount for

distribution between the two players28. As this motive cannot
operate
in the risk experiment, it can only increase transfers levels in
the trust
experiment. Our interpretation of oxytocin’s effect on trust in
terms
of betrayal aversion may be seen in the light of animal studies
indicating that increased availability of oxytocin in the central
nervous system facilitates approach behaviour, by linking the
over-
coming of social avoidance with the activation of brain circuits
implicated in reward (for example, the nucleus
accumbens)12,15.
The ubiquity of trusting behaviour is perhaps one of the dis-
tinguishing features of the human species. An element of trust
characterizes almost all human social interactions. Here we
have
sought to examine the effect of oxytocin on trust in humans.
Research in non-human mammals suggests that oxytocin has a
key
role in social attachment and affiliation. We find that intranasal
administration of oxytocin causes a substantial increase in
trusting
behaviour. Subjects given oxytocin seem better able to
overcome
trust obstacles such as betrayal aversion. Of course, this finding
could
be misused to induce trusting behaviours that selfish actors sub-
sequently exploit. However, our findings may also have positive
clinical implications for patients with mental disorders that are
associated with social dysfunctions (for example, social phobia
or
autism). In particular, social phobia ranks as the third most
common
mental health disorder and is characterized by marked social

deficits,
including persistent fear and avoidance of social interactions.
Thus,
our results might lead to fertile research on the role of oxytocin
in
several mental health disorders with major public health
significance.
METHODS
Subjects. A total of 194 healthy male students (mean age ^ s.d.,
22.0 ^ 3.4 yr)
from different universities in Zurich participated in the study.
The trust
experiment had 128 participants, and 66 subjects participated in
the risk
experiment. Exclusion criteria for participation were significant
medical or
psychiatric illness, medication, smoking more than 15 cigarettes
per day, and
drug or alcohol abuse. Subjects were instructed to abstain from
food and drink
(other than water) for 2 h before the experiment, and from
alcohol, smoking and
caffeine for 24 h before the experiment. Participants were
informed at the time of
recruitment that the experiment would evaluate the effects of a
hormone on
decision making. In total, 16 individuals out of the original
sample of 194 were
excluded because of incorrect substance administration (7 in the
trust experi-
ment, 5 in the risk experiment) or their stated disbelief that the
opponent in the
trust game was actually a human being (4 participants). The
study protocol was
approved by the ethics committee of the University of Zurich.

All subjects gave
written, informed consent before participation.
Substance administration. Subjects received a single intranasal
dose of 24 IU
oxytocin (Syntocinon-Spray, Novartis; 3 puffs per nostril, each
with 4 IU
oxytocin) or placebo 50 min before the start of the trust or the
risk experiment.
Subjects were randomly assigned to the oxytocin or placebo
group (double-
blind, placebo-controlled study design). In order to avoid any
subjective
substance effects (for example, olfactory effects) other than
those caused by
oxytocin, the placebo contained all inactive ingredients except
for the
neuropeptide.
Behavioural experiment and questionnaires. After substance
administration,
Figure 3 | Average back transfer of trustees to their investors.
The graph
shows the average back transfer by trustees for different levels
of investor
transfer in the oxytocin and placebo groups. The dotted line
shows the level
of the back transfer necessary to achieve payoff equality
between the investor
and the trustee. The dashed line shows a level of back transfer
equal to the
investor’s transfer to the trustee. The trustees’ back transfers
are on average
slightly higher than the amount sent by the investor. Trustees in

both
treatment groups make higher back transfers in response to
higher original
investor transfer levels. However, there is no statistically
significant
difference in back transfers between subjects in the oxytocin
and the placebo
groups.
NATURE|Vol 435|2 June 2005 LETTERS
675
subjects completed questionnaires on a computer to measure
demographic
items and psychological characteristics. Owing to the crucial
role of the social
environment in triggering behavioural effects of oxytocin (as
shown in animal
research)13,29, subjects were asked to wait in the rest area
while the next part of the
experiment was prepared. During this 5-min waiting period,
subjects were seated
at different tables. Subjects at the same table could talk to each
other, but at the
beginning of the experiment they were informed that they would
not be
interacting with those subjects who sat at the same table. When
subjects re-
entered the laboratory for both experiments, they received
written instructions

(available from the authors on request) explaining the payoff
structure of the
experiment and the private payment procedure at the end of the
experiment.
Subjects were randomly and anonymously assigned to the role
of investor or
trustee in the trust experiment, and did not know the identity of
the persons with
whom they were matched. After subjects had read the
instructions in each
experiment, we checked whether they understood the payoff
structure by means
of several hypothetical examples. All subjects (with one
exception) answered the
control questions correctly. One subject did not answer the
control questions
correctly and was excluded from the data set (this subject also
did not apply the
substance correctly). In addition, subjects received an oral
summary of the
instructions.
Each subject in the trust experiment made four decisions in the
same player
role while paired with different, randomly selected interaction
partners. No pair
of subjects interacted twice. Subjects in the role of the investor
received no
feedback about the trustee’s decision between the different
interactions. After
every transfer decision, each investor was asked about his belief
with regard to
the expected back transfer from the trustee. Notably, trust levels
were statistically
constant across the four decisions. There is no time trend in
investors’ decisions

in either the oxytocin or the placebo group. In the risk
experiment, everything
was identical to the trust experiment, except that all subjects
played the role of an
investor who could transfer 0, 4, 8, or 12 MU into a project
rather than to a
trustee. In particular, an investor’s payoff risk (that is, the
distribution of payoffs)
in the risk experiment was identical to that in the trust
experiment at any feasible
transfer level.
To measure alterations in the psychological state of subjects
throughout the
course of the experiment, we assessed their mood and calmness
at the beginning
of the experiment (before substance administration) and
immediately before the
trust experiment or the risk experiment, by means of a suitable
questionnaire26.
All decisions in the experiments and the answers to the
questionnaires were
entered on a computer using z-Tree software30. Subjects
received a flat fee of 80
Swiss francs for participation in the experiment; each MU
earned in the trust and
the risk experiment was worth 0.40 Swiss francs.
Received 20 April; accepted 5 May 2005.
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Acknowledgements This paper is part of the Research Priority
Program
‘Foundations of Human Social Behaviour — Altruism versus
Egoism’ at the
University of Zurich. Financial support from the MacArthur
Foundation
(Network on Economic Environments and the Evolution of
Individual Preferences
and Social Norms) and the Cogito Foundation is gratefully
acknowledged. M.H.
also acknowledges support from the Swiss National Science
Foundation. We
thank F. Heusi, A. Enzler, S. Gilomen, E. Götz, M.
Koenigsberg, K. Korsunsky,
S. Krammer, S. Lauber, P. Obrist-Rybar, M. Schellhammer, B.
Studer, R. Stünzi

and M. Trottmann for research assistance.
Author Information Reprints and permissions information is
available at
npg.nature.com/reprintsandpermissions. The authors declare no
competing
financial interests. Correspondence and requests for materials
should be
addressed to E.F. ([email protected]) and M.H.
([email protected]).
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676

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