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Cognitive Bias Modification in Mental

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Cognitive Bias Modification in Mental

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Cognitive Bias Modification
in Mental
MEG M. REULAND, SHARI A. STEINMAN, and BETHANY A. TEACHMAN

Abstract
Cognitive biases refer to a tendency to favor a particular way of processing information, such as habitually attending to threatening information in the environment, or
interpreting ambiguous information in a negative way. Importantly, cognitive biases
are linked to a number of emotional problems, such as anxiety and depression, raising the question of whether altering cognitive biases could relieve the symptoms
of these disorders. Cognitive bias modification (CBM) refers to a group of interventions typically delivered via computer that alter cognitive biases through repeated
practice in processing information in a healthy way (e.g., learning to attend to neutral, rather than threatening, cues). Some research suggests that CBM can ameliorate
symptoms of mental illness and reduce emotional vulnerability to stressors. Moreover, CBM’s computerized format offers a potentially cost-effective option for wide
dissemination, which could prevent and reduce the public health burden of mental
illness. At the same time, mixed research findings suggest more research is needed
before CBM can be considered a frontline treatment for psychopathology. The current
essay describes CBM’s theoretical framework, reviews the CBM outcome literature,
and explores key questions for future research, such as how CBM works, for whom
it works best, and optimal delivery conditions.

INTRODUCTION
Cognitive biases reflect a tendency for individuals to favor one way of
processing information over others, such as anxious individuals preferentially attending to threatening information, or depressed people selectively
remembering failure-related information (MacLeod & Mathews, 2012).
Biases have been identified in many areas of cognitive processing, including
attention, interpretation, and memory. Some cognitive biases facilitate adaptive processing. For example, some individuals habitually attend to friendly
faces at a party, which leads to their social engagement and enjoyment.
Other cognitive biases, however, may contribute to maladaptive information
processing. For example, a college student whose attention gets stuck on
the one hostile face at a party may experience anxiety and avoid similar
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

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situations in the future. These patterns of thinking can be so powerful that
they play a causal role in the onset and maintenance of anxiety, depression,
and other mental illnesses.
Cognitive bias modification (CBM) interventions are a group of
“therapist-free” treatments that are administered on a computer or via
other technology, and involve sustained practice processing information in
an adaptive way. CBM training programs aim to change cognitive biases,
and test whether changing biases can cause changes in emotional distress
and maladaptive behaviors, such as social avoidance. In addition to this
critical theoretical test, CBM may have important clinical implications.
CBM interventions have sometimes been shown to reduce symptoms of
psychopathology, and diminish avoidance behavior and distress in the
face of stressors. Yet, results across studies have been quite mixed. Thus,
for CBM to achieve its full promise, there is considerable need to replicate
earlier findings; understand how CBM works (i.e., mechanisms underlying
change); increase the reliability, strength, and durability of CBM’s effects;
and explore new ways of delivering CBM interventions.
FOUNDATIONAL RESEARCH
COGNITIVE MODELS OF MENTAL ILLNESS
Cognitive models posit that individuals are constantly attending to and interpreting information in their environment in a biased way that can dramatically influence how the world is perceived and understood (Clark & Beck,
2010). For example, individuals with panic disorder preferentially attend to
bodily signs of potential danger, such as a rapid heartbeat, and may interpret
them as threatening (e.g., assume the rapid heartbeat signals an impending
heart attack, as opposed to resulting from racing up the stairs). This biased
processing style is theorized to lead to negative emotions such as anxiety or
sadness, and makes it more difficult for the individual to respond effectively
in emotionally stressful situations (e.g., a person may avoid the situation altogether).
While numerous cognitive biases have been identified, we focus on
attention and interpretation biases because the majority of CBM research
has focused on shifting these biases. Attention bias refers to a tendency to
preferentially attend to negative or threatening information in the environment, and/or difficulty withdrawing attention from this information. When
the college student’s attention is drawn to the one unfriendly face at the
party, she is exhibiting an attention bias. Interpretation bias occurs when
an individual habitually makes one type of inference when a situation is
ambiguous and could be interpreted either positively or negatively. For

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example, when the college student notices that others at the party are
looking at her, she may infer that they think she looks stupid, instead of
assigning a more positive meaning, such as that they think she is wearing a
nice outfit.
These thinking patterns are closely associated with depression, anxiety,
and related emotional disorders. Depressed individuals show selective
attention to information consistent with their sad mood, a tendency to
interpret ambiguous information negatively, and a pattern of remembering
the negative aspects of an event, (i.e., memory bias; Hallion & Ruscio,
2011). Several cognitive biases have also been linked to specific anxiety
disorders (MacLeod & Mathews, 2012). For example, individuals with panic
disorder may preferentially attend to bodily sensations, such as feeling
short-of-breath following physical exertion, and interpret it as sign of
an impending health catastrophe. In social situations, people with social
anxiety tend to focus attention on themselves, as well as faces perceived as
hostile or unfriendly, and assume others are negatively evaluating them.
ASSESSING AND MODIFYING COGNITIVE BIASES
Several computerized tasks have been designed to detect cognitive biases,
and many of these same tasks have been altered to train particular response
styles using classic reinforcement principles. By introducing feedback aimed
at increasing desired responses and decreasing others, these tasks attempt
to shift cognitive biases. In the dot probe paradigm (MacLeod, Mathews, &
Tata, 1986), one of the most commonly used assessments of attention bias,
participants are briefly presented with a pair of either words or pictures on a
computer screen. Typically, one item is threatening while the other is benign.
For example, a dot probe for spider phobia may feature a close-up image of a
tarantula (threatening image) next to an image of a teaspoon (benign image).
Immediately after the pictures disappear, a letter (e.g., E or F) appears in the
location of the screen formerly occupied by one of the items, and participants
are directed to press a button that corresponds to the letter as quickly as possible. A quick response indicates that the participant may have already been
attending to the location on the screen where the letter appears, and a longer
response suggests that their attention had been focused elsewhere. Comparing participants’ response times to letters replacing threatening versus
benign items provides a measure of attention bias. To train a more positive
bias, the letter consistently appears in the location where the benign item had
appeared, so participants learn to direct their attention to the benign item
before the letter is presented.
Tasks that assess or alter interpretation bias often involve resolving ambiguous information in either a threatening or benign way (MacLeod & Mathews,

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2012). In one interpretation bias assessment, participants are asked to spell
homophones that have both a negative and positive/neutral referent (e.g.,
die or dye, guilt or gilt). How often a participant provides the negative referent suggests a negative interpretation bias (Mathews, Richards, & Eysenck,
1989). In another task, participants read ambiguous scenarios that could be
interpreted in either a threatening or benign light, such as “you walk into the
party and guests begin laughing.” The sentence could indicate the person
walking in is being ridiculed, or the guests could be laughing at something
completely unrelated to the person. Both the homophones and the scenarios
tasks can be used to train a more positive interpretation style by designing
the task so participants are forced to assign benign, nonthreating meanings to
resolve the ambiguity. For example, in the scenarios task, participants would
be asked to fill in the missing letter in a word that finishes the scenario in a
positive way (e.g., the guests at the party must have been laughing at a j_ke;
participants would press “o” to make the word “joke”).
There are now numerous forms of bias training, including, but not limited
to, tasks to shift memory biases to encourage less selective recalling of negative information (Joormann, Hertel, LeMoult, & Gotlib, 2009); tasks to shift
implicit associations, which are automatic associations in memory (Clerkin
& Teachman, 2010); tasks that encourage less negative imagery (Torkan et al.,
2014); tasks to train approach and avoidance tendencies (Asnaani, Rinck,
Becker, & Hofmann, 2014); and tasks to inhibit ruminating on depressing
thoughts (Daches & Mor, 2014).
CBM FOR MENTAL HEALTH PROBLEMS
CBM FOR ANXIETY
CBM studies targeting anxiety have yielded some promising findings. In
two studies (Amir, Beard, et al., 2009; Schmidt, Richey, Buckner, & Timpano,
2009), clinically diagnosed socially phobic participants who underwent
CBM-A showed symptom reduction commensurate with the current gold
standard treatment for social anxiety, cognitive behavior therapy. Symptoms
of generalized anxiety disorder, characterized by pervasive and persistent
worrying, have also been significantly alleviated with CBM-A (Amir, Beard,
Burns, & Bomyea, 2009). CBM-I has been similarly effective in reducing
symptoms of social anxiety (Hirsch, Mathews, & Clark, 2007) and worry
(Hirsch, Hayes, & Mathews, 2009), among other domains. In a recent
demonstration of the potential clinical utility of CBM-I, height fearful participants who received CBM-I improved as much as participants who received
exposure therapy, the current gold standard treatment for height phobia
(Steinman & Teachman, 2014). This suggests that CBM-I may potentially

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provide a palatable, accessible, low-cost, therapist-free intervention for
anxiety.
Notwithstanding such advances, the literature also includes many lackluster findings (e.g., improvements by the CBM training group were no greater
than those of a control group that received no intervention; Fox, Mackintosh,
& Holmes, 2014). A recent statistical analysis integrating findings from a
large number of studies, known as a meta-analysis, found only small effects
of CBM-I and CBM-A on anxiety, although larger effects on changing bias
(Hallion & Ruscio, 2011). Generally, results were stronger for CBM-I (vs
CBM-A), when participants received multiple training sessions, and when
symptoms were measured during or after a stressful task designed to show
whether training reduced emotional vulnerability. Another meta-analysis
of only CBM-A studies (Beard, Sawyer, & Hofmann, 2012) corroborated a
small, but significant effect of CBM-A.
CBM FOR DEPRESSION
The Hallion and Ruscio (2011) meta-analysis presents a somewhat sobering
picture of CBM for depression, suggesting positive findings could be due to
chance. However, several CBM studies have found reductions in depressive
symptoms, and some of the earlier null findings used training programs
that did not focus specifically on depression-linked biases or lacked some
key features that we now know can enhance effects (e.g., incorporating
imagery into the training). For example, when participants were instructed
to imagine training scenarios, rather than thinking about only their verbal
meaning, CBM with imagery was linked to better coping during a task
designed to evoke negative mood (Holmes, Lang, & Shah, 2009). Moreover,
imagery-based CBM-I has reduced depressive symptoms in clinically
depressed samples (Lang, Blackwell, Harmer, Davison, & Holmes, 2012).
Clearly, more research is needed to determine whether CBM can help
treat or prevent depression, but we see these early results and other novel
CBM paradigms designed to shift depression-linked biases (e.g., related to
autobiographical memory; Schartau, Dalgleish, & Dunn, 2009) as promising.
CBM FOR OTHER DISORDERS
Given evidence that alcohol-related cognitive biases are tied to severity of
addiction, craving, and relapse, alcohol dependence is a natural target for
CBM. In one study (Schoenmakers, de Bruin, Lux, Goertz, Van Kerkhof,
& Wiers, 2010), alcohol-dependent participants trained to disengage their
attention from alcohol-related images improved faster than untrained
participants. CBM for alcohol dependence has also aimed to alter patients’

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tendencies to approach (vs avoid) alcohol-related images, such as by training
an individual to “push away” a picture of a beer bottle using a joystick.
Participants who received CBM targeting avoidance as an adjunct to traditional cognitive behavioral therapy showed greater treatment outcomes
1 year later, compared to those who received cognitive behavioral therapy
only (Wiers, Eberl, Rinck, Becker, & Lindenmeyer, 2011). These results
were replicated in a later study (Eberl, Wiers, Pawelczack, Rinck, Becker,
& Lindenmeyer, 2013) that also found that change in approach/avoid bias
toward alcohol partly accounted for treatment outcomes 1 year later. These
findings highlight the causal role of cognitive biases in psychopathology
and the promise of CBM to ameliorate hazardous drinking.
The CBM research literature includes attempts to intervene in several other
mental health problems and related areas, including (but not limited to)
cigarette addiction (Attwood, O’Sullivan, Leonards, Mackintosh, & Munafo,
2008); eating disorders (Smith & Rieger, 2009); chronic pain (Sharpe, Ianiello,
Dear, Perry, Refshauge, & Nicholas, 2012); and anxiety symptoms occurring
simultaneously with schizophrenia (Steel, Wykes, Ruddle, Smith, Shah,
& Holmes, 2010). Testing novel applications for CBM may hold promise
for reducing symptoms of many disabling conditions, but the literature
suggests it does not work well in all cases. Thus, it will be important to
determine what problem areas (e.g., type of disorder) and which individuals
can benefit from CBM.
CBM FOR YOUTH
Given that cognitive biases may increase vulnerability to later disorder,
youth may provide a critical opportunity for prevention efforts (Lau, 2013).
Several studies involving youth have reported changes in interpretation
following training, an indication that youths’ cognitive bias may be malleable. However, studies that show improvements in mood or functioning
following interpretation change are rare, raising questions about CBM’s
clinical utility for youth. Notwithstanding, similar to the trend seen in adult
CBM studies, effects on mood and functioning have emerged when training
is followed by a stressful task. In one CBM-I study (Lau, Belli, & Chopra,
2013), teens who received positive training reported less anxiety after a challenging task (i.e., solving math problems out loud while being videotaped)
than those who received negative training, highlighting positive cognitions
as a possible buffer against stress.
Studies of CBM-A in children and adolescents are also mixed but include
some promising results. In one study, 12 out of 16 clinically diagnosed
anxious youth no longer met diagnostic criteria following attention training
(Rozenman, Weersing, & Amir, 2011). However, a study that included a

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larger sample of children without anxiety disorders failed to show training
effects (Eldar, Ricon, & Bar-Haim, 2008). CBM-A has also been studied as an
adjunctive treatment to cognitive behavioral therapy. In a recent study that
paired an active and placebo CBM-A treatment with cognitive behavioral
therapy, both the active and placebo groups achieved greater reductions
in anxiety than a group receiving only cognitive behavioral therapy, as
reported by their clinicians. The active CBM-A group, however, improved
most according to the children themselves and their parents (Shechner
et al., 2014). Considering that up to 50% of youth fail to make significant
gains after cognitive behavioral therapy, the prospect of improving these
outcomes with the addition of CBM-A is exciting.
KEY ISSUES FOR FUTURE RESEARCH
The research reviewed above provides compelling evidence that CBM
has important theoretical and clinical applications. However, much of the
research on CBM has occurred in the past decade. As such, the field is ripe
with questions for future researchers to explore. In this section, we review
several key questions for future research, including: how can we strengthen
CBM’s effects, who is CBM most likely to help, how does CBM work, how
should we deliver CBM, and what challenges are expected for CBM research
moving forward?
HOW CAN WE STRENGTHEN CBM’S EFFECTS?
While a growing number of CBM studies have shown significant shifts in bias
in expected directions, some CBM studies have found shifts in bias in unexpected directions or none at all (Fox et al., 2014). To increase the strength,
reliability, and durability of CBM’s effects on bias change, future research
should investigate the type of training materials that lead to the strongest
results (e.g., pictures vs words for CBM-A); the optimal number of trials in a
CBM session (e.g., number of ambiguous scenarios in CBM-I); and the optimal number of CBM sessions (e.g., six vs eight sessions). Drawing from other
literatures may be useful in this pursuit. For example, the cognitive science
and learning literatures may inform study design decisions regarding the
optimal amount of time needed between sessions to consolidate learning,
and the effects of increasing the difficulty of completing CBM paradigms to
maintain participants’ motivation (Hertel & Mathews, 2011).
For CBM to have true clinical utility, future researchers must evaluate not
only how to increase CBM’s ability to shift cognitive biases, but also how
to strengthen CBM’s effects on reducing psychopathology (also known as

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far transfer effects; see Hertel & Mathews, 2011). Several additions or modifications to existing designs may lead to stronger far transfer effects. These
include conducting CBM training in situations that are closely related to the
patient’s psychopathology (e.g., completing CBM related to height phobia
while on a balcony); individualizing training (e.g., using participant’s name
or picture in CBM training stimuli; e.g., Clerkin & Teachman, 2010); or
reinforcing CBM when participants encounter stressors in the future (e.g.,
providing brief “booster” sessions in the stressful context using a portable
device, such as a smartphone).
WHO IS CBM MOST LIKELY TO HELP?
Another goal for future research is to understand which individuals are most
likely to benefit from CBM. For instance, individuals with higher levels of
cognitive bias may be more likely to benefit, because they presumably have
more “room” to change. On the other hand, individuals with lower levels
of cognitive bias may be most likely to benefit, because their biases may be
more flexible and less ingrained. Also currently unknown is which types of
psychopathology are most likely to be alleviated via CBM. Additional factors
that may predict who is most likely to benefit from CBM include demographics (e.g., age, gender, race), symptom severity, and genetic predisposition (see
Fox, Zougkou, Ridgewell, & Garner, 2011, for a study on alleles and CBM).
HOW DOES CBM WORK?
Understanding the mechanisms (i.e., how it works) underlying CBM is
another interesting avenue for future research. Cognitive theory posits
that CBM’s effect on psychopathology is via shifting cognitive bias, and
several CBM studies have found evidence that change in bias mediates (i.e.,
accounts for) change in psychopathology symptoms (Steinman & Teachman,
2014). However, CBM may affect psychopathology via exposing individuals
to cues relevant to their disorder (e.g., showing spider phobic individuals
scenarios about spiders), which is similar to more traditional types of
therapy (e.g., exposure therapy for anxiety; though see Beadel, Smyth, &
Teachman, 2014, for evidence against an exposure-based mechanism). Other
possible mechanisms of CBM include increases in cognitive flexibility (i.e.,
the ability to redirect cognitive processes) and changes in explicit learning
(i.e., consciously learning what to pay attention to, or how to interpret
ambiguous cues). Clearly, augmenting our current understanding of the
mechanisms underlying CBM is likely to strengthen its effects.

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HOW SHOULD WE DELIVER CBM?
Another important question for CBM researchers is how best to deliver CBM.
Much CBM research currently takes place on computers in the laboratory,
but some studies have begun testing CBM paradigms online (Salemink,
Kindt, Rienties, & van den Hout, 2014) and on other portable devices,
such as smart-phones and tablets (e.g., Enock, Hofmann, & McNally, 2014).
However, results for these early studies delivering CBM outside the lab
have been mixed. For instance, See, MacLeod, and Bridle (2009) found that
web-based CBM-A significantly reduced attentional bias to negative cues
and anxiety in response to a stressor, relative to a control condition. On the
contrary, Salemink et al. (2014) found that while web-based CBM-I successfully modified interpretations to be more positive and less negative relative
to a control group, both CBM-I and control conditions led to similar changes
in psychopathology symptoms (i.e., anxiety, depression, and distress). These
mixed results highlight the need to evaluate different delivery methods to
determine which are most likely to be cost-effective and accessible, while
still producing the desired effects of bias shift and symptom reduction,
compared to control conditions. Further, formats that make CBM more
engaging, such as those resembling video games, might enhance delivery of
CBM in environments that do not have the high level of control and minimal
distraction available in the laboratory (Fox et al., 2014).
WHAT CHALLENGES ARE EXPECTED FOR CBM RESEARCH MOVING FORWARD?
Coordinating the mix of interdisciplinary investigators that can optimize
CBM’s effects is an important challenge to making real progress in CBM
research. Cognitive scientists can contribute knowledge regarding learning,
memory, automatic processing, and optimal paradigms for measuring cognitive bias. Clinical psychologists can contribute a theoretical understanding
of the role of bias in psychopathology, and what is needed to reduce the
burden of psychopathology. Psychologists and public health experts who
specialize in dissemination of treatments can help evaluate the best ways to
deliver CBM to those who could benefit from it. As CBM paradigms become
more elaborate, collaboration with computer scientists and program developers will need to increase. Further, it is likely that future researchers will
want to better understand the role of genetics and neurological processes
in CBM.
Another challenge is achieving the optimal scope for CBM studies. Larger
sample sizes are needed to test moderators (i.e., factors that influence the
effectiveness of training) and mediators (i.e., mechanisms explaining how
CBM works). Additionally, studies are needed to test durability of treatment

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effects and transfer of gains beyond cognitive change and immediate symptom reduction.
As the CBM field continues to expand, it will spark debate. Under what
conditions should CBM provide a stand-alone treatment, versus an adjunct
or preventative treatment? Does CBM rely on the same mechanisms as
other established treatments? Does CBM devalue the role of clinicians? (We
hope not, given the authors of this essay are also practicing evidence-based
clinicians!) How much research support is needed before CBM should be
included in mainstream clinical care?
CBM research has mostly occurred in the clinical and health psychology
fields, but these emerging research trends and debates are likely relevant to
several other fields. For example, CBM may be used to modify biases that
result in prejudice against marginalized groups. CBM findings also lead to
intriguing philosophical quandaries: does being told to change your thinking
(e.g., forced to select a positive word or assign a positive meaning) really
constitute a change in thinking, or is it simply an ephemeral effect following
from experimental demands?
In sum, CBM is a field ripe for future research that integrates multiple disciplines. Current and future CBM findings have the potential to dramatically
shift mental health treatment delivery systems, and to greatly advance theoretical understanding of psychopathology.
ACKNOWLEDGMENTS
We are grateful for Nauder Namaky’s assistance on this essay.
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Training in perspective broadening reduces self-reported affect and psychophysiological response to distressing films and autobiographical memories. Journal of
Abnormal Psychology, 118(1), 15–27. doi:10.1037/a0012906
Shechner, T., Rimon-Chakir, A., Britton, J. C., Lotan, D., Apter, A., Bliese, P. D., … ,
Bar-Haim, Y. (2014). Attention bias modification treatment augmenting effects on
cognitive behavioral therapy in children with anxiety: Randomized controlled
trial Journal of the American Academy of Child & Adolescent Psychiatry, 53(1), 61–71.
doi:10.1016/j.jaac.2013.09.016
Schmidt, N. B., Richey, J. A., Buckner, J. D., & Timpano, K. R. (2009). Attention training for generalized social anxiety disorder. Journal of Abnormal Psychology, 118(1),
5–14. doi:10.1037/a0013643
Schoenmakers, T. M., de Bruin, M., Lux, I. F. M., Goertz, A. G., Van Kerkhof, D. H.
A. T., & Wiers, R. W. (2010). Clinical effectiveness of attentional bias modification training in abstinent alcoholic patients. Drug and Alcohol Dependence, 109(1–3),
30–36. doi:10.1016/j.drugalcdep.2009.11.022
See, J., MacLeod, C., & Bridle, R. (2009). The reduction of anxiety vulnerability through the modification of attentional bias: A real-world study using a

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home-based cognitive bias modification procedure. Journal of Abnormal Psychology,
118(1), 65–75. doi:10.1037/a0014377
Sharpe, L., Ianiello, M., Dear, B. F., Perry, K. N., Refshauge, K., & Nicholas, M. K.
(2012). Is there a potential role for attention bias modification in pain patients?
Results of 2 randomised, controlled trials. PAIN, 153(3), 722–731. doi:10.1016/
j.pain.2011.12.014
Smith, E., & Rieger, E. (2009). The effect of attentional training on body dissatisfaction and dietary restriction. European Eating Disorders Review, 17(3), 169–176.
doi:10.1002/erv.921
Steel, C., Wykes, T., Ruddle, A., Smith, G., Shah, D. M., & Holmes, E. A. (2010).
Can we harness computerised cognitive bias modification to treat anxiety in
schizophrenia? A first step highlighting the role of mental imagery. Psychiatry
Research, 178(3), 451–455. doi:10.1016/j.psychres.2010.04.042
Steinman, S. A., & Teachman, B. A. (2014). Reaching new heights: Comparing interpretation bias modification to exposure therapy for extreme height fear. Journal of
Consulting and Clinical Psychology. doi:10.1037/a0036023
Torkan, H., Blackwell, S. E., Holmes, E. A., Kalantari, M., Neshat-Doost, H. T.,
Maroufi, M., & Talebi, H. (2014). Positive imagery cognitive bias modification in
treatment-seeking patients with major depression in Iran: A pilot study. Cognitive
Therapy and Research, 38(1), 132–145. doi:10.1007/s10608-014-9598-8
Wiers, R. W., Eberl, C., Rinck, M., Becker, E. S., & Lindenmeyer, J. (2011). Retraining automatic action tendencies changes alcoholic patients’ approach bias for
alcohol and improves treatment outcome. Psychological Science, 22(4), 490–497.
doi:10.1177/0956797611400615

FURTHER READING
Beard, C., Sawyer, A. T., & Hofmann, S. G. (2012). Efficacy of attention bias modification using threat and appetite stimuli: A meta-analytic review. Behavior Therapy,
43(4), 724–740.
Hakamata, Y., Lissek, S., Bar-Haim, Y., Britton, J. C., Fox, N. A., Leibenluft, E., … ,
Pine, D. S. (2010). Attention bias modification treatment: A meta-analysis toward
the establishment of novel treatment for anxiety. Biological Psychiatry, 68, 982–990.
doi:10.1016/j.biopsych.2010.07.021
Hallion, L. S., & Ruscio, A. M. (2011). A meta-analysis of the effect of cognitive bias
modification on anxiety and depression. Psychological Bulletin, 137(6), 940–958.
doi:10.1037/a0024355
Lau, J. Y. F. (2013). Cognitive bias modification of interpretations: A viable treatment
for child and adolescent anxiety? Behaviour Research and Therapy, 51(10), 614–622.
doi:10.1016/j.brat.2013.07.001
MacLeod, C., & Mathews, A. (2012). Cognitive bias modification approaches to
anxiety. Annual Review of Clinical Psychology, 8, 189–217. doi:10.1146/annurevclinpsy-032511-143052

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Schmidt, N. B., Richey, J. A., Buckner, J. D., & Timpano, K. R. (2009). Attention training for generalized social anxiety disorder. Journal of Abnormal Psychology, 118(1),
5–14. doi:10.1037/a0013643
Steinman, S. A., & Teachman, B. A. (2014). Reaching new heights: Comparing interpretation bias modification to exposure therapy for extreme height fear. Journal of
Consulting and Clinical Psychology. doi:10.1037/a0036023

MEG M. REULAND SHORT BIOGRAPHY
Meg M. Reuland is a doctoral candidate at the University of Virginia. She
received her MA from Teachers College and the University of Virginia, and
her BA from Yale College. Meg is interested in interventions for child and
adolescent psychopathology that address the contexts in which development
occurs, particularly school and family. She recently piloted an online CBM
intervention for early adolescents with social anxiety and their parents, and
is interested in future investigations of CBM as a stand-alone or adjunctive
treatment for anxiety problems of childhood and adolescence.
SHARI A. STEINMAN SHORT BIOGRAPHY
Shari A. Steinman is a predoctoral intern at the Institute of Living, and a doctoral candidate at the University of Virginia. She received her MA from the
University of Virginia, and her BS. from Washington University in St. Louis.
Shari’s research interests include evaluating and modifying cognitive biases
among individuals with anxiety disorders. Shari’s clinical interests include
using evidence-based treatments to help individuals with anxiety, OCD, and
depression.
Personal Webpage: sharisteinman.weebly.com
BETHANY A. TEACHMAN SHORT BIOGRAPHY
Bethany A. Teachman is an Associate Professor and the Director of Clinical Training at the University of Virginia in the Department of Psychology.
She received her PhD from Yale University and BA from the University of
British Columbia. Her research focuses on biases in cognitive processing that
contribute to the development and maintenance of anxiety disorders, with a
particular interest in investigating how automatic cognitive processes can be
modified. In addition, she teaches undergraduate and graduate level courses
in psychopathology, and trains graduate students learning to do therapy.
Dr. Teachman is a licensed clinical psychologist who specializes in cognitive
behavior therapy. She is an author on over 100 publications, including the
books Treatment Planning in Psychotherapy: Taking the Guesswork Out of Clinical

Cognitive Bias Modification in Mental

15

Care (2002, Guilford Press) and Helping Your Child Overcome an Eating Disorder:
What You Can Do at Home (2003, New Harbinger). Dr. Teachman is associate
editor for the journal Perspectives on Psychological Science, winner of the 2012
American Psychological Association (APA) Distinguished Scientific Award
for Early Career Contribution to Psychology, and is the 2014 President of the
Society for a Science of Clinical Psychology.
Lab Webpage: www.teachman.org
Project Implicit Mental Health: www.ImplicitMentalHealth.com
RELATED ESSAYS
What Is Neuroticism, and Can We Treat It? (Psychology), Amantia Ametaj
et al.
Aggression and Victimization (Psychology), Sheri Bauman and Aryn Taylor
Genetics and the Life Course (Sociology), Evan Charney
Peers and Adolescent Risk Taking (Psychology), Jason Chein
Clarifying the Nature and Structure of Personality Disorder (Psychology),
Takakuni Suzuki and Douglas B. Samuel
Delusions (Psychology), Max Coltheart
Misinformation and How to Correct It (Psychology), John Cook et al.
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(Psychology), Angélique Cramer and Denny Borsboom
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Patrick S. Forscher and Patricia G. Devine
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Depression (Psychology), Ian H. Gotlib and Daniella J. Furman
Positive Emotion Disturbance (Psychology), June Gruber and John Purcell
Family Relationships and Development (Psychology), Joan E. Grusec
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G. Harvey
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et al.
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Horwitz
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J. C. Huntjens and Martin J. Dorahy
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Kendall et al.
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Shinobu Kitayama and Sarah Huff

16

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and
Marie-H. Monfils
Understanding Risk-Taking Behavior: Insights from Evolutionary Psychology (Psychology), Karin Machluf and David F. Bjorklund
Evolutionary Perspectives on Animal and Human Personality (Anthropology), Joseph H. Manson and Lynn A. Fairbanks
Disorders of Consciousness (Psychology), Martin M. Monti
Social Classification (Sociology), Elizabeth G. Pontikes
Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til
Wykes
Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.
Born This Way: Thinking Sociologically about Essentialism (Sociology),
Kristen Schilt
Taking Personality to the Next Level: What Does It Mean to Know a Person?
(Psychology), Simine Vazire and Robert Wilson
A Gene-Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.
Crime and the Life Course (Sociology), Mark Warr and Carmen Gutierrez
Rumination (Psychology), Edward R. Watkins
Emotion Regulation (Psychology), Paree Zarolia et al.



Cognitive Bias Modification
in Mental
MEG M. REULAND, SHARI A. STEINMAN, and BETHANY A. TEACHMAN

Abstract
Cognitive biases refer to a tendency to favor a particular way of processing information, such as habitually attending to threatening information in the environment, or
interpreting ambiguous information in a negative way. Importantly, cognitive biases
are linked to a number of emotional problems, such as anxiety and depression, raising the question of whether altering cognitive biases could relieve the symptoms
of these disorders. Cognitive bias modification (CBM) refers to a group of interventions typically delivered via computer that alter cognitive biases through repeated
practice in processing information in a healthy way (e.g., learning to attend to neutral, rather than threatening, cues). Some research suggests that CBM can ameliorate
symptoms of mental illness and reduce emotional vulnerability to stressors. Moreover, CBM’s computerized format offers a potentially cost-effective option for wide
dissemination, which could prevent and reduce the public health burden of mental
illness. At the same time, mixed research findings suggest more research is needed
before CBM can be considered a frontline treatment for psychopathology. The current
essay describes CBM’s theoretical framework, reviews the CBM outcome literature,
and explores key questions for future research, such as how CBM works, for whom
it works best, and optimal delivery conditions.

INTRODUCTION
Cognitive biases reflect a tendency for individuals to favor one way of
processing information over others, such as anxious individuals preferentially attending to threatening information, or depressed people selectively
remembering failure-related information (MacLeod & Mathews, 2012).
Biases have been identified in many areas of cognitive processing, including
attention, interpretation, and memory. Some cognitive biases facilitate adaptive processing. For example, some individuals habitually attend to friendly
faces at a party, which leads to their social engagement and enjoyment.
Other cognitive biases, however, may contribute to maladaptive information
processing. For example, a college student whose attention gets stuck on
the one hostile face at a party may experience anxiety and avoid similar
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

situations in the future. These patterns of thinking can be so powerful that
they play a causal role in the onset and maintenance of anxiety, depression,
and other mental illnesses.
Cognitive bias modification (CBM) interventions are a group of
“therapist-free” treatments that are administered on a computer or via
other technology, and involve sustained practice processing information in
an adaptive way. CBM training programs aim to change cognitive biases,
and test whether changing biases can cause changes in emotional distress
and maladaptive behaviors, such as social avoidance. In addition to this
critical theoretical test, CBM may have important clinical implications.
CBM interventions have sometimes been shown to reduce symptoms of
psychopathology, and diminish avoidance behavior and distress in the
face of stressors. Yet, results across studies have been quite mixed. Thus,
for CBM to achieve its full promise, there is considerable need to replicate
earlier findings; understand how CBM works (i.e., mechanisms underlying
change); increase the reliability, strength, and durability of CBM’s effects;
and explore new ways of delivering CBM interventions.
FOUNDATIONAL RESEARCH
COGNITIVE MODELS OF MENTAL ILLNESS
Cognitive models posit that individuals are constantly attending to and interpreting information in their environment in a biased way that can dramatically influence how the world is perceived and understood (Clark & Beck,
2010). For example, individuals with panic disorder preferentially attend to
bodily signs of potential danger, such as a rapid heartbeat, and may interpret
them as threatening (e.g., assume the rapid heartbeat signals an impending
heart attack, as opposed to resulting from racing up the stairs). This biased
processing style is theorized to lead to negative emotions such as anxiety or
sadness, and makes it more difficult for the individual to respond effectively
in emotionally stressful situations (e.g., a person may avoid the situation altogether).
While numerous cognitive biases have been identified, we focus on
attention and interpretation biases because the majority of CBM research
has focused on shifting these biases. Attention bias refers to a tendency to
preferentially attend to negative or threatening information in the environment, and/or difficulty withdrawing attention from this information. When
the college student’s attention is drawn to the one unfriendly face at the
party, she is exhibiting an attention bias. Interpretation bias occurs when
an individual habitually makes one type of inference when a situation is
ambiguous and could be interpreted either positively or negatively. For

Cognitive Bias Modification in Mental

3

example, when the college student notices that others at the party are
looking at her, she may infer that they think she looks stupid, instead of
assigning a more positive meaning, such as that they think she is wearing a
nice outfit.
These thinking patterns are closely associated with depression, anxiety,
and related emotional disorders. Depressed individuals show selective
attention to information consistent with their sad mood, a tendency to
interpret ambiguous information negatively, and a pattern of remembering
the negative aspects of an event, (i.e., memory bias; Hallion & Ruscio,
2011). Several cognitive biases have also been linked to specific anxiety
disorders (MacLeod & Mathews, 2012). For example, individuals with panic
disorder may preferentially attend to bodily sensations, such as feeling
short-of-breath following physical exertion, and interpret it as sign of
an impending health catastrophe. In social situations, people with social
anxiety tend to focus attention on themselves, as well as faces perceived as
hostile or unfriendly, and assume others are negatively evaluating them.
ASSESSING AND MODIFYING COGNITIVE BIASES
Several computerized tasks have been designed to detect cognitive biases,
and many of these same tasks have been altered to train particular response
styles using classic reinforcement principles. By introducing feedback aimed
at increasing desired responses and decreasing others, these tasks attempt
to shift cognitive biases. In the dot probe paradigm (MacLeod, Mathews, &
Tata, 1986), one of the most commonly used assessments of attention bias,
participants are briefly presented with a pair of either words or pictures on a
computer screen. Typically, one item is threatening while the other is benign.
For example, a dot probe for spider phobia may feature a close-up image of a
tarantula (threatening image) next to an image of a teaspoon (benign image).
Immediately after the pictures disappear, a letter (e.g., E or F) appears in the
location of the screen formerly occupied by one of the items, and participants
are directed to press a button that corresponds to the letter as quickly as possible. A quick response indicates that the participant may have already been
attending to the location on the screen where the letter appears, and a longer
response suggests that their attention had been focused elsewhere. Comparing participants’ response times to letters replacing threatening versus
benign items provides a measure of attention bias. To train a more positive
bias, the letter consistently appears in the location where the benign item had
appeared, so participants learn to direct their attention to the benign item
before the letter is presented.
Tasks that assess or alter interpretation bias often involve resolving ambiguous information in either a threatening or benign way (MacLeod & Mathews,

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

2012). In one interpretation bias assessment, participants are asked to spell
homophones that have both a negative and positive/neutral referent (e.g.,
die or dye, guilt or gilt). How often a participant provides the negative referent suggests a negative interpretation bias (Mathews, Richards, & Eysenck,
1989). In another task, participants read ambiguous scenarios that could be
interpreted in either a threatening or benign light, such as “you walk into the
party and guests begin laughing.” The sentence could indicate the person
walking in is being ridiculed, or the guests could be laughing at something
completely unrelated to the person. Both the homophones and the scenarios
tasks can be used to train a more positive interpretation style by designing
the task so participants are forced to assign benign, nonthreating meanings to
resolve the ambiguity. For example, in the scenarios task, participants would
be asked to fill in the missing letter in a word that finishes the scenario in a
positive way (e.g., the guests at the party must have been laughing at a j_ke;
participants would press “o” to make the word “joke”).
There are now numerous forms of bias training, including, but not limited
to, tasks to shift memory biases to encourage less selective recalling of negative information (Joormann, Hertel, LeMoult, & Gotlib, 2009); tasks to shift
implicit associations, which are automatic associations in memory (Clerkin
& Teachman, 2010); tasks that encourage less negative imagery (Torkan et al.,
2014); tasks to train approach and avoidance tendencies (Asnaani, Rinck,
Becker, & Hofmann, 2014); and tasks to inhibit ruminating on depressing
thoughts (Daches & Mor, 2014).
CBM FOR MENTAL HEALTH PROBLEMS
CBM FOR ANXIETY
CBM studies targeting anxiety have yielded some promising findings. In
two studies (Amir, Beard, et al., 2009; Schmidt, Richey, Buckner, & Timpano,
2009), clinically diagnosed socially phobic participants who underwent
CBM-A showed symptom reduction commensurate with the current gold
standard treatment for social anxiety, cognitive behavior therapy. Symptoms
of generalized anxiety disorder, characterized by pervasive and persistent
worrying, have also been significantly alleviated with CBM-A (Amir, Beard,
Burns, & Bomyea, 2009). CBM-I has been similarly effective in reducing
symptoms of social anxiety (Hirsch, Mathews, & Clark, 2007) and worry
(Hirsch, Hayes, & Mathews, 2009), among other domains. In a recent
demonstration of the potential clinical utility of CBM-I, height fearful participants who received CBM-I improved as much as participants who received
exposure therapy, the current gold standard treatment for height phobia
(Steinman & Teachman, 2014). This suggests that CBM-I may potentially

Cognitive Bias Modification in Mental

5

provide a palatable, accessible, low-cost, therapist-free intervention for
anxiety.
Notwithstanding such advances, the literature also includes many lackluster findings (e.g., improvements by the CBM training group were no greater
than those of a control group that received no intervention; Fox, Mackintosh,
& Holmes, 2014). A recent statistical analysis integrating findings from a
large number of studies, known as a meta-analysis, found only small effects
of CBM-I and CBM-A on anxiety, although larger effects on changing bias
(Hallion & Ruscio, 2011). Generally, results were stronger for CBM-I (vs
CBM-A), when participants received multiple training sessions, and when
symptoms were measured during or after a stressful task designed to show
whether training reduced emotional vulnerability. Another meta-analysis
of only CBM-A studies (Beard, Sawyer, & Hofmann, 2012) corroborated a
small, but significant effect of CBM-A.
CBM FOR DEPRESSION
The Hallion and Ruscio (2011) meta-analysis presents a somewhat sobering
picture of CBM for depression, suggesting positive findings could be due to
chance. However, several CBM studies have found reductions in depressive
symptoms, and some of the earlier null findings used training programs
that did not focus specifically on depression-linked biases or lacked some
key features that we now know can enhance effects (e.g., incorporating
imagery into the training). For example, when participants were instructed
to imagine training scenarios, rather than thinking about only their verbal
meaning, CBM with imagery was linked to better coping during a task
designed to evoke negative mood (Holmes, Lang, & Shah, 2009). Moreover,
imagery-based CBM-I has reduced depressive symptoms in clinically
depressed samples (Lang, Blackwell, Harmer, Davison, & Holmes, 2012).
Clearly, more research is needed to determine whether CBM can help
treat or prevent depression, but we see these early results and other novel
CBM paradigms designed to shift depression-linked biases (e.g., related to
autobiographical memory; Schartau, Dalgleish, & Dunn, 2009) as promising.
CBM FOR OTHER DISORDERS
Given evidence that alcohol-related cognitive biases are tied to severity of
addiction, craving, and relapse, alcohol dependence is a natural target for
CBM. In one study (Schoenmakers, de Bruin, Lux, Goertz, Van Kerkhof,
& Wiers, 2010), alcohol-dependent participants trained to disengage their
attention from alcohol-related images improved faster than untrained
participants. CBM for alcohol dependence has also aimed to alter patients’

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

tendencies to approach (vs avoid) alcohol-related images, such as by training
an individual to “push away” a picture of a beer bottle using a joystick.
Participants who received CBM targeting avoidance as an adjunct to traditional cognitive behavioral therapy showed greater treatment outcomes
1 year later, compared to those who received cognitive behavioral therapy
only (Wiers, Eberl, Rinck, Becker, & Lindenmeyer, 2011). These results
were replicated in a later study (Eberl, Wiers, Pawelczack, Rinck, Becker,
& Lindenmeyer, 2013) that also found that change in approach/avoid bias
toward alcohol partly accounted for treatment outcomes 1 year later. These
findings highlight the causal role of cognitive biases in psychopathology
and the promise of CBM to ameliorate hazardous drinking.
The CBM research literature includes attempts to intervene in several other
mental health problems and related areas, including (but not limited to)
cigarette addiction (Attwood, O’Sullivan, Leonards, Mackintosh, & Munafo,
2008); eating disorders (Smith & Rieger, 2009); chronic pain (Sharpe, Ianiello,
Dear, Perry, Refshauge, & Nicholas, 2012); and anxiety symptoms occurring
simultaneously with schizophrenia (Steel, Wykes, Ruddle, Smith, Shah,
& Holmes, 2010). Testing novel applications for CBM may hold promise
for reducing symptoms of many disabling conditions, but the literature
suggests it does not work well in all cases. Thus, it will be important to
determine what problem areas (e.g., type of disorder) and which individuals
can benefit from CBM.
CBM FOR YOUTH
Given that cognitive biases may increase vulnerability to later disorder,
youth may provide a critical opportunity for prevention efforts (Lau, 2013).
Several studies involving youth have reported changes in interpretation
following training, an indication that youths’ cognitive bias may be malleable. However, studies that show improvements in mood or functioning
following interpretation change are rare, raising questions about CBM’s
clinical utility for youth. Notwithstanding, similar to the trend seen in adult
CBM studies, effects on mood and functioning have emerged when training
is followed by a stressful task. In one CBM-I study (Lau, Belli, & Chopra,
2013), teens who received positive training reported less anxiety after a challenging task (i.e., solving math problems out loud while being videotaped)
than those who received negative training, highlighting positive cognitions
as a possible buffer against stress.
Studies of CBM-A in children and adolescents are also mixed but include
some promising results. In one study, 12 out of 16 clinically diagnosed
anxious youth no longer met diagnostic criteria following attention training
(Rozenman, Weersing, & Amir, 2011). However, a study that included a

Cognitive Bias Modification in Mental

7

larger sample of children without anxiety disorders failed to show training
effects (Eldar, Ricon, & Bar-Haim, 2008). CBM-A has also been studied as an
adjunctive treatment to cognitive behavioral therapy. In a recent study that
paired an active and placebo CBM-A treatment with cognitive behavioral
therapy, both the active and placebo groups achieved greater reductions
in anxiety than a group receiving only cognitive behavioral therapy, as
reported by their clinicians. The active CBM-A group, however, improved
most according to the children themselves and their parents (Shechner
et al., 2014). Considering that up to 50% of youth fail to make significant
gains after cognitive behavioral therapy, the prospect of improving these
outcomes with the addition of CBM-A is exciting.
KEY ISSUES FOR FUTURE RESEARCH
The research reviewed above provides compelling evidence that CBM
has important theoretical and clinical applications. However, much of the
research on CBM has occurred in the past decade. As such, the field is ripe
with questions for future researchers to explore. In this section, we review
several key questions for future research, including: how can we strengthen
CBM’s effects, who is CBM most likely to help, how does CBM work, how
should we deliver CBM, and what challenges are expected for CBM research
moving forward?
HOW CAN WE STRENGTHEN CBM’S EFFECTS?
While a growing number of CBM studies have shown significant shifts in bias
in expected directions, some CBM studies have found shifts in bias in unexpected directions or none at all (Fox et al., 2014). To increase the strength,
reliability, and durability of CBM’s effects on bias change, future research
should investigate the type of training materials that lead to the strongest
results (e.g., pictures vs words for CBM-A); the optimal number of trials in a
CBM session (e.g., number of ambiguous scenarios in CBM-I); and the optimal number of CBM sessions (e.g., six vs eight sessions). Drawing from other
literatures may be useful in this pursuit. For example, the cognitive science
and learning literatures may inform study design decisions regarding the
optimal amount of time needed between sessions to consolidate learning,
and the effects of increasing the difficulty of completing CBM paradigms to
maintain participants’ motivation (Hertel & Mathews, 2011).
For CBM to have true clinical utility, future researchers must evaluate not
only how to increase CBM’s ability to shift cognitive biases, but also how
to strengthen CBM’s effects on reducing psychopathology (also known as

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

far transfer effects; see Hertel & Mathews, 2011). Several additions or modifications to existing designs may lead to stronger far transfer effects. These
include conducting CBM training in situations that are closely related to the
patient’s psychopathology (e.g., completing CBM related to height phobia
while on a balcony); individualizing training (e.g., using participant’s name
or picture in CBM training stimuli; e.g., Clerkin & Teachman, 2010); or
reinforcing CBM when participants encounter stressors in the future (e.g.,
providing brief “booster” sessions in the stressful context using a portable
device, such as a smartphone).
WHO IS CBM MOST LIKELY TO HELP?
Another goal for future research is to understand which individuals are most
likely to benefit from CBM. For instance, individuals with higher levels of
cognitive bias may be more likely to benefit, because they presumably have
more “room” to change. On the other hand, individuals with lower levels
of cognitive bias may be most likely to benefit, because their biases may be
more flexible and less ingrained. Also currently unknown is which types of
psychopathology are most likely to be alleviated via CBM. Additional factors
that may predict who is most likely to benefit from CBM include demographics (e.g., age, gender, race), symptom severity, and genetic predisposition (see
Fox, Zougkou, Ridgewell, & Garner, 2011, for a study on alleles and CBM).
HOW DOES CBM WORK?
Understanding the mechanisms (i.e., how it works) underlying CBM is
another interesting avenue for future research. Cognitive theory posits
that CBM’s effect on psychopathology is via shifting cognitive bias, and
several CBM studies have found evidence that change in bias mediates (i.e.,
accounts for) change in psychopathology symptoms (Steinman & Teachman,
2014). However, CBM may affect psychopathology via exposing individuals
to cues relevant to their disorder (e.g., showing spider phobic individuals
scenarios about spiders), which is similar to more traditional types of
therapy (e.g., exposure therapy for anxiety; though see Beadel, Smyth, &
Teachman, 2014, for evidence against an exposure-based mechanism). Other
possible mechanisms of CBM include increases in cognitive flexibility (i.e.,
the ability to redirect cognitive processes) and changes in explicit learning
(i.e., consciously learning what to pay attention to, or how to interpret
ambiguous cues). Clearly, augmenting our current understanding of the
mechanisms underlying CBM is likely to strengthen its effects.

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HOW SHOULD WE DELIVER CBM?
Another important question for CBM researchers is how best to deliver CBM.
Much CBM research currently takes place on computers in the laboratory,
but some studies have begun testing CBM paradigms online (Salemink,
Kindt, Rienties, & van den Hout, 2014) and on other portable devices,
such as smart-phones and tablets (e.g., Enock, Hofmann, & McNally, 2014).
However, results for these early studies delivering CBM outside the lab
have been mixed. For instance, See, MacLeod, and Bridle (2009) found that
web-based CBM-A significantly reduced attentional bias to negative cues
and anxiety in response to a stressor, relative to a control condition. On the
contrary, Salemink et al. (2014) found that while web-based CBM-I successfully modified interpretations to be more positive and less negative relative
to a control group, both CBM-I and control conditions led to similar changes
in psychopathology symptoms (i.e., anxiety, depression, and distress). These
mixed results highlight the need to evaluate different delivery methods to
determine which are most likely to be cost-effective and accessible, while
still producing the desired effects of bias shift and symptom reduction,
compared to control conditions. Further, formats that make CBM more
engaging, such as those resembling video games, might enhance delivery of
CBM in environments that do not have the high level of control and minimal
distraction available in the laboratory (Fox et al., 2014).
WHAT CHALLENGES ARE EXPECTED FOR CBM RESEARCH MOVING FORWARD?
Coordinating the mix of interdisciplinary investigators that can optimize
CBM’s effects is an important challenge to making real progress in CBM
research. Cognitive scientists can contribute knowledge regarding learning,
memory, automatic processing, and optimal paradigms for measuring cognitive bias. Clinical psychologists can contribute a theoretical understanding
of the role of bias in psychopathology, and what is needed to reduce the
burden of psychopathology. Psychologists and public health experts who
specialize in dissemination of treatments can help evaluate the best ways to
deliver CBM to those who could benefit from it. As CBM paradigms become
more elaborate, collaboration with computer scientists and program developers will need to increase. Further, it is likely that future researchers will
want to better understand the role of genetics and neurological processes
in CBM.
Another challenge is achieving the optimal scope for CBM studies. Larger
sample sizes are needed to test moderators (i.e., factors that influence the
effectiveness of training) and mediators (i.e., mechanisms explaining how
CBM works). Additionally, studies are needed to test durability of treatment

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

effects and transfer of gains beyond cognitive change and immediate symptom reduction.
As the CBM field continues to expand, it will spark debate. Under what
conditions should CBM provide a stand-alone treatment, versus an adjunct
or preventative treatment? Does CBM rely on the same mechanisms as
other established treatments? Does CBM devalue the role of clinicians? (We
hope not, given the authors of this essay are also practicing evidence-based
clinicians!) How much research support is needed before CBM should be
included in mainstream clinical care?
CBM research has mostly occurred in the clinical and health psychology
fields, but these emerging research trends and debates are likely relevant to
several other fields. For example, CBM may be used to modify biases that
result in prejudice against marginalized groups. CBM findings also lead to
intriguing philosophical quandaries: does being told to change your thinking
(e.g., forced to select a positive word or assign a positive meaning) really
constitute a change in thinking, or is it simply an ephemeral effect following
from experimental demands?
In sum, CBM is a field ripe for future research that integrates multiple disciplines. Current and future CBM findings have the potential to dramatically
shift mental health treatment delivery systems, and to greatly advance theoretical understanding of psychopathology.
ACKNOWLEDGMENTS
We are grateful for Nauder Namaky’s assistance on this essay.
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FURTHER READING
Beard, C., Sawyer, A. T., & Hofmann, S. G. (2012). Efficacy of attention bias modification using threat and appetite stimuli: A meta-analytic review. Behavior Therapy,
43(4), 724–740.
Hakamata, Y., Lissek, S., Bar-Haim, Y., Britton, J. C., Fox, N. A., Leibenluft, E., … ,
Pine, D. S. (2010). Attention bias modification treatment: A meta-analysis toward
the establishment of novel treatment for anxiety. Biological Psychiatry, 68, 982–990.
doi:10.1016/j.biopsych.2010.07.021
Hallion, L. S., & Ruscio, A. M. (2011). A meta-analysis of the effect of cognitive bias
modification on anxiety and depression. Psychological Bulletin, 137(6), 940–958.
doi:10.1037/a0024355
Lau, J. Y. F. (2013). Cognitive bias modification of interpretations: A viable treatment
for child and adolescent anxiety? Behaviour Research and Therapy, 51(10), 614–622.
doi:10.1016/j.brat.2013.07.001
MacLeod, C., & Mathews, A. (2012). Cognitive bias modification approaches to
anxiety. Annual Review of Clinical Psychology, 8, 189–217. doi:10.1146/annurevclinpsy-032511-143052

14

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Schmidt, N. B., Richey, J. A., Buckner, J. D., & Timpano, K. R. (2009). Attention training for generalized social anxiety disorder. Journal of Abnormal Psychology, 118(1),
5–14. doi:10.1037/a0013643
Steinman, S. A., & Teachman, B. A. (2014). Reaching new heights: Comparing interpretation bias modification to exposure therapy for extreme height fear. Journal of
Consulting and Clinical Psychology. doi:10.1037/a0036023

MEG M. REULAND SHORT BIOGRAPHY
Meg M. Reuland is a doctoral candidate at the University of Virginia. She
received her MA from Teachers College and the University of Virginia, and
her BA from Yale College. Meg is interested in interventions for child and
adolescent psychopathology that address the contexts in which development
occurs, particularly school and family. She recently piloted an online CBM
intervention for early adolescents with social anxiety and their parents, and
is interested in future investigations of CBM as a stand-alone or adjunctive
treatment for anxiety problems of childhood and adolescence.
SHARI A. STEINMAN SHORT BIOGRAPHY
Shari A. Steinman is a predoctoral intern at the Institute of Living, and a doctoral candidate at the University of Virginia. She received her MA from the
University of Virginia, and her BS. from Washington University in St. Louis.
Shari’s research interests include evaluating and modifying cognitive biases
among individuals with anxiety disorders. Shari’s clinical interests include
using evidence-based treatments to help individuals with anxiety, OCD, and
depression.
Personal Webpage: sharisteinman.weebly.com
BETHANY A. TEACHMAN SHORT BIOGRAPHY
Bethany A. Teachman is an Associate Professor and the Director of Clinical Training at the University of Virginia in the Department of Psychology.
She received her PhD from Yale University and BA from the University of
British Columbia. Her research focuses on biases in cognitive processing that
contribute to the development and maintenance of anxiety disorders, with a
particular interest in investigating how automatic cognitive processes can be
modified. In addition, she teaches undergraduate and graduate level courses
in psychopathology, and trains graduate students learning to do therapy.
Dr. Teachman is a licensed clinical psychologist who specializes in cognitive
behavior therapy. She is an author on over 100 publications, including the
books Treatment Planning in Psychotherapy: Taking the Guesswork Out of Clinical

Cognitive Bias Modification in Mental

15

Care (2002, Guilford Press) and Helping Your Child Overcome an Eating Disorder:
What You Can Do at Home (2003, New Harbinger). Dr. Teachman is associate
editor for the journal Perspectives on Psychological Science, winner of the 2012
American Psychological Association (APA) Distinguished Scientific Award
for Early Career Contribution to Psychology, and is the 2014 President of the
Society for a Science of Clinical Psychology.
Lab Webpage: www.teachman.org
Project Implicit Mental Health: www.ImplicitMentalHealth.com
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