How does cognitive therapy work? Cognitive change and symptom change in cognitive therapy and pharmacotherapy for depression.

The effects of changes in depression-relevant cognition were examined in relation to subsequent change in depressive symptoms for outpatients with major depressive disorder randomly assigned to cognitive therapy (COT; n?=?32) vs those assigned to pharmacotherapy only (NoCT; n?=?32). Depression severity scores were obtained at the beginning, middle, and end of the 12-wk treatment period, as were scores on 4 measures of cognition: Attributional Styles Questionnaire (ASQ), Automatic Thoughts Questionnaire (S. D. Hollon and P. E. Kendall; see record 1981-20180-001), Dysfunctional Attitudes Scale (DAS), and the Hopelessness Scale (HS). Change from pretreatment to midtreatment on the ASQ, DAS, and HS predicted change in depression from midtreatment to posttreatment in the COT group, but not in the NoCT group. It is concluded that cognitive phenomena play mediational roles in COT. However, data do not support their status as sufficient mediators. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist competence in cognitive therapy for depression: Predicting subsequent symptom change.

Objective: The efficacy of cognitive therapy (CT) for depression has been well established. Measures of the adequacy of therapists' delivery of treatment are critical to facilitating therapist training and treatment dissemination. While some studies have shown an association between CT competence and outcome, researchers have yet to address whether competence ratings predict subsequent outcomes. Method: In a sample of 60 moderately to severely depressed outpatients from a clinical trial, we examined competence ratings (using the Cognitive Therapy Scale) as a predictor of subsequent symptom change. Results: Competence ratings predicted session-to-session symptom change early in treatment. In analyses focused on prediction of symptom change following 4 early sessions through the end of 16 weeks of treatment, competence was shown to be a significant predictor of evaluator-rated end-of-treatment depressive symptom severity and was predictive of self-reported symptom severity at the level of a nonsignificant trend. To investigate whether competence is more important to clients with specific complicating features, we examined 4 patient characteristics as potential moderators of the competence-outcome relation. Competence was more highly related to subsequent outcome for patients with higher anxiety, an earlier age of onset, and (at a trend level) patients with a chronic form of depression (chronic depression or dysthymia) than for those patients without these characteristics. Competence ratings were not more predictive of subsequent outcomes among patients who met (vs. those who did not meet) criteria for a personality disorder (i.e., among personality disorders represented in the clinical trial). Conclusions: These findings provide support for the potential utility of CT competence ratings in applied settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders.

Participants were 30 adult outpatients diagnosed with avoidant personality disorder or obsessive-compulsive personality disorder who enrolled in an open trial of cognitive therapy for personality disorders. Treatment consisted of up to 52 weekly sessions. Symptom evaluations were conducted at intake, at Sessions 17 and 34, and at the last session. Alliance variables were patients' first alliance rating and "rupture-repair" episodes, which are disruptions in the therapeutic relationship that can provide corrective experiences and facilitate change. Stronger early alliances and rupture-repair episodes predicted more improvement in symptoms of personality disorder and depression. This work points to potentially important areas to target in treatment development for these personality disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Explanatory style change during cognitive therapy for unipolar depression.

We administered the Attributional Style Questionnaire to 39 unipolar depressed patients at the beginning and end of cognitive therapy and at one-year follow-up, and we administered it to 12 bipolar patients during a depressed episode. A pessimistic explanatory style for bad events correlated with severity of depression for unipolars at cognitive therapy intake (r?=?.56, p?     

Mediators and moderators of change in cognitive therapy of depression.

Reviews the theoretical and empirical literature associated with the mediators and moderators of change in cognitive therapy (CT) of depression. Covariation between change in cognition and change in depression, specific effects for cognitive vs behavioral components of CT, specific effects for CT vs other treatments, moderating influence of nonspecific and technical aspects of the therapeutic environment, and moderating influence of client characteristics are reviewed. The clinical implications of prior research and suggestions for future research on identifying the critical ingredients of change in CT of depression are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression.

This study reports on the relationship of therapist competence to the outcome of cognitive-behavioral treatment in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Outpatients suffering from major depressive disorder were treated by cognitive-behavioral therapists at each of 3 U.S. sites using a format of 20 sessions in 16 weeks. Findings provide some support for the relationship of therapist competence (as measured by the Cognitive Therapy Scale) to reduction of depressive symptomatology when controlling for therapist adherence and facilitative conditions. The results are, however, not as strong or consistent as expected. The component of competence that was most highly related to outcome is a factor that reflects the therapist's ability to structure the treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive change and the therapeutic alliance: The role of technical and nontechnical factors in cognitive therapy.

Tests whether there are reciprocal interactions between the technical and nontechnical aspects of cognitive therapy (CT). 47 outpatients (mean age 36.8 yrs) with a depressive and/or anxiety disorder were treated with a 20-week, manualized CT intervention. Measures included the Beck Depression Inventory, the Dysfunctional Attitude Scale, and the Working Alliance Inventory. Results indicate that pretreatment depressogenic cognitions impact on the ability to form an early therapeutic alliance, whereas pretreatment depression severity is unrelated to alliance formation. Second, the degree to which patients were in agreement with the goals and tasks of therapy was predictive of subsequent change in depressogenic cognitions. Third, the 2-way interaction between the therapeutic bond and cognitive-change scores was found to predict depression outcomes: patients who reported a better therapeutic bond and who experienced greater reduction in their depressogenic cognitions, experienced the most favorable clinical outcomes. Certain aspects of the therapeutic alliance (i.e., goals and tasks) may facilitate the implementation of the technical factors of CT, while other aspects of the alliance (i.e., bond) act in concert with technical factors to produce direct effects on depressed symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Discontinuities and cognitive changes in an exposure-based cognitive therapy for depression.

Significant shifts or discontinuities in symptom course can mark points of transition and reveal important change processes. The authors investigated 2 patterns of change in depression-the rapid early response and a transient period of apparent worsening that the authors call a depression spike. Participants were 29 patients diagnosed with major depressive disorder who enrolled in an open trial of an exposure-based cognitive therapy. Hierarchical linear modeling revealed an overall cubic shape of symptom change and that both the rapid response and spike patterns predicted lower posttreatment depression. Patients wrote weekly narratives about their depression. Early narratives of rapid responders were coded as having more hope than those of nonrapid responders. The narratives of patients with a depression spike had more cognitive-emotional processing during this period of arousal than those without a spike. Findings are discussed in the context of cognitive-emotional processing theories in depression and anxiety disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals.

Objective: To evaluate cognitive-behavioral therapy to enhance medication adherence and reduce depression (CBT-AD) in individuals with HIV. Design: A two arm, randomized, controlled, cross-over trial comparing CBT-AD to enhanced treatment as usual only (ETAU). ETAU, which both groups received, included a single-session intervention for adherence and a letter to the patient's provider documenting her or his continued depression. The intervention group also received 10 to 12 sessions of CBT-AD. Main Outcome Measures: Adherence to antiretroviral therapy as assessed by Medication Event Monitoring Systems (MEMs) and depression as assessed by blinded structured evaluation. Results: At the acute outcome assessment (3-months), those who received CBT-AD evidenced significantly greater improvements in medication adherence and depression relative to the comparison group. Those who were originally assigned to the comparison group who chose to cross over to CBT-AD showed similar improvements in both depression and adherence outcomes. Treatment gains for those in the intervention group were generally maintained at 6- and 12-month follow-up assessments. By the end of the follow-up period, those originally assigned CBT-AD demonstrated improvements in plasma HIV RNA concentrations, though these differences did not emerge before the cross-over, and hence there were not between-groups differences. Conclusions: CBT-AD is a potentially efficacious approach for individuals with HIV struggling with depression and adherence. Replication and extension in larger efficacy trials are needed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client interpersonal and cognitive styles as predictors of response to time-limited cognitive therapy for depression.

This study examined the relationship between cognitive and interpersonal styles and outcome among 24 clients who received time-limited cognitive therapy for depression. The authors hypothesized that this relationship would be mediated by therapeutic alliance. They found that clients' interpersonal style, particularly an underinvolved style, was predictive of treatment outcome. As predicted, the impact of this style on outcome was mediated through the therapeutic alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mindfulness-based cognitive therapy to prevent relapse in recurrent depression.

For people at risk of depressive relapse, mindfulness-based cognitive therapy (MBCT) has an additive benefit to usual care (H. F. Coelho, P. H. Canter, & E. Ernst, 2007). This study asked if, among patients with recurrent depression who are treated with antidepressant medication (ADM), MBCT is comparable to treatment with maintenance ADM (m-ADM) in (a) depressive relapse prevention, (b) key secondary outcomes, and (c) cost effectiveness. The study design was a parallel 2-group randomized controlled trial comparing those on m-ADM (N = 62) with those receiving MBCT plus support to taper/discontinue antidepressants (N = 61). Relapse/recurrence rates over 15-month follow-ups in MBCT were 47%, compared with 60% in the m-ADM group (hazard ratio = 0.63; 95% confidence interval: 0.39 to 1.04). MBCT was more effective than m-ADM in reducing residual depressive symptoms and psychiatric comorbidity and in improving quality of life in the physical and psychological domains. There was no difference in average annual cost between the 2 groups. Rates of ADM usage in the MBCT group was significantly reduced, and 46 patients (75%) completely discontinued their ADM. For patients treated with ADM, MBCT may provide an alternative approach for relapse prevention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relevance of the supervisory alliance to the counseling alliance and to treatment adherence in counselor training.

The quality of the supervisory working alliance should be related to the quality of the counseling working alliance and to trainee adherence to a treatment model. After each of 4 supervision sessions, 75 trainees completed the Supervisory Working Alliance Inventory, and, after each counseling session, their clients completed the Working Alliance Inventory. Judges rated portions of the videotaped counseling sessions with an adherence measure. Hierarchical linear modeling was used to analyze these nested data (repeated measures of trainees nested within supervisors). As hypothesized, the trainee's perception of the supervisory alliance was significantly related to the client's perception of the counseling alliance and to aspects of treatment adherence. The significance of these findings is discussed in relation to the supervision literature. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient interpersonal impacts and the early therapeutic alliance in interpersonal therapy for depression.

The therapeutic alliance consistently predicts positive psychotherapy outcomes. Thus, it is important to uncover factors that relate to alliance development. The goal of this study was to examine the association between patient interpersonal characteristics and alliance quality in interpersonal therapy for depression. Data derive from a subsample (n = 74) of a larger naturalistic database of outpatients treated at a mood disorders clinic of a university-affiliated psychiatric hospital. Following Session 3 of treatment, therapists completed the Impact Message Inventory (Kiesler & Schmidt, 1993) to assess patients' interpersonal impacts on them. Also following Session 3, patients completed the Working Alliance Inventory (Horvath & Greenberg, 1989) to assess alliance quality. As predicted, patients' affiliative interpersonal impacts, as perceived by their therapists, were positively associated with alliance quality, controlling for baseline depression severity. Although unrelated to the initial hypotheses, patients concurrently taking psychotropic medications reported better alliances than patients receiving psychotherapy only. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Researcher allegiance and meta-analysis: The case of cognitive therapy for depression.

K. S. Dobson (see record 1989-30221-001) conducted a meta-analysis of 28 studies of cognitive-behavioral therapy for depression that used the Beck Depression Inventory as outcome measure. He concluded that the outcome of this type of therapy was superior to that of other forms of psychotherapy and to that of pharmacotherapy. The present study reanalyzed the same studies, and a further set of 37 similar ones published from 1987 to 1994, taking into account variations in sample size and researcher allegiance. This study confirmed Dobson's conclusions for his original sample but showed that about half the difference between CT and other treatments was predictable from researcher allegiance. However, comparable analyses of the later set of studies showed no effect of researcher allegiance. Two causes for these phenomena are (a) a historical effect, whereby both effect sizes and allegiance were large in earlier years and declined over time and (b) a treatment effect whereby effect size and allegiance were correlated, but more for some treatments than others. This correlation has also weakened over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient pretreatment interpersonal problems and therapeutic alliance in short-term cognitive therapy.

The growing consensus regarding the importance of interpersonal process in psychotherapy, as well as of interpersonal factors in self-definition, has underscored the relevance of examining patient interpersonal functioning as it relates to the development of the therapeutic alliance. This study examined the relationship of patient pretreatment interpersonal functioning, as measured by the Inventory of Interpersonal Problems and the Millon Clinical Multiaxial Inventory (MCMI), to the therapeutic alliance, as measured early in treatment by a patient self-report version of the Working Alliance Inventory. On the basis of an interpersonal circumplex interpretation, the results generally indicated that friendly-submissive interpersonal problems were positively related to the development of aspects of the alliance and that hostile-dominant problems were negatively related to the development of aspects of the alliance early in short-term cognitive therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of homework in cognitive behavior therapy of depression.

Homework is particularly important in the cognitive-behavioral treatment of depression because the pervasive nature of the characteristic cognitive, affective, and motivational disturbances undercut the impact of didactic and supportive verbal interventions. Despite the importance of homework, a relatively small number of studies have quantified the causal relationship between homework completion and symptomatic outcome. Most of these studies have limited power to detect small-to-moderate effect sizes and rely on retrospective or incomplete measurements of homework that do not distinguish between the quantity and quality of the assigned tasks. Nevertheless, there is relatively consistent evidence from correlational studies to conclude that homework adherence is associated with significantly better outcomes. These findings point to new questions for research (i.e., does ongoing use of homework decrease the likelihood of relapse following termination of time-limited therapy?) and have implications for clinical practice. Examples of homework assignments are provided and strategies to improve homework adherence are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The alliance in couple therapy: Partner influence, early change, and alliance patterns in a naturalistic sample.

Objective: The purpose of this study was to explore the relationship between the alliance and outcome in couple therapy and examine whether the alliance predicted outcomes over and above early change. The authors also investigated partner influence and gender and sought to identify couple alliance patterns that predicted couple outcomes. Method: The authors examined the alliances and outcomes at posttreatment and follow-up of 250 couples seeking treatment for marital distress in a naturalistic setting. The Session Rating Scale was used to measure the alliance; the Outcome Rating Scale and Locke Wallace Marital Adjustment Scale were used to measure outcomes. Couples were White, Euro-Scandinavian, and heterosexual, with a mean age of 38.5 years and average number of years together of 11.8. On a subsample (n = 118) that included couples with 4 or more sessions, the authors investigated the relationship between the alliance and outcome controlling for early change, and patterns of alliance development were delineated. Results: In the full sample, first-session alliances were not predictive of outcomes, but last-session alliances were predictive for both individuals and their partners. In the subsample, third-session alliances predicted outcome significantly above early change (d = 0.25) that exceeded the reliable change index. Couple alliances that started over the mean and increased were associated with significantly more couples achieving reliable or clinically significant change. Gender influences were mixed. Conclusions: Given the current findings suggesting a potential alliance impact over and above symptom relief as well as the importance of ascending alliance scores, continuous assessment of the alliance appears warranted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Two aspects of the therapeutic alliance: Differential relations with depressive symptom change.

Objective: The therapeutic alliance has been linked to symptom change in numerous investigations. Although the alliance is commonly conceptualized as a multidimensional construct, few studies have examined its components separately. The current study explored which components of the alliance are most highly associated with depressive symptom change in cognitive therapy (CT). Method: Data were drawn from 2 published randomized, controlled clinical trials of CT for major depressive disorder (n = 105, mean age = 40 years, female = 62%, White = 82%). We examined the relations of 2 factor-analytically derived components of the Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989) with symptom change on the Beck Depression Inventory—II (BDI–II; Beck, Steer, & Brown, 1996) that occurred either prior to or subsequent to the examined sessions. WAI ratings were obtained at an early and a late session for each therapist–patient dyad. Results: Variation in symptom change subsequent to the early session was significantly related to the WAI factor that assesses therapist–patient agreement on the goals and tasks of therapy but not to a factor assessing the affective bond between therapist and patient. In contrast, both factors, when assessed in a late session, were significantly predicted by prior symptom change. Conclusions: These findings may reflect the importance, in CT, of therapist–patient agreement on the goals and tasks of therapy. In contrast, the bond between therapist and patient may be more of a consequence than a cause of symptom change in CT. The implications of these results and directions for future research are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Response to cognitive therapy in depression: The role of maladaptive beliefs and personality disorders.

This study examined whether personality disorder status and beliefs that characterize personality disorders affect response to cognitive therapy. In a naturalistic study, 162 depressed outpatients with and without a personality disorder were followed over the course of cognitive therapy. As would be hypothesized by cognitive theory (A. T. Beck & A. Freeman, 1990), it was not personality disorder status but rather maladaptive avoidant and paranoid beliefs that predicted variance in outcome. However, pre- to posttherapy comparisons suggested that although patients with or without comorbidity respond comparably to "real-world" cognitive therapy, they report more severe depressive symptomatology at intake and more residual symptoms at termination. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sudden gains in cognitive therapy of depression and depression relapse/recurrence.

Cognitive therapy (CT) may have significant advantages over antidepressants in preventing depression relapses. Many CT patients experience sudden gains: large symptom improvement in 1 between-session interval. Past studies have associated CT sudden gains with in-session cognitive changes but not with life events. This study examined sudden gains and depression relapse/recurrence among 60 CT clinical-trial patients. Survival analyses showed that only one third of sudden-gain-responders relapsed in 2 years, and they had 74% lower relapse risks than did non-sudden-gain-responders. Among patients with sustained responses, 73% experienced sudden gains. The authors also replicated J. R. Vittengl, L. A. Clark, and R. B. Jarrett's (see record 2005-01321-021) finding that sudden gains identified with their unique criteria did not predict relapse. The current authors' findings suggest that CT sudden gains are not measurement artifacts, and that sudden gains and their causes and consequences might be important in preventing relapses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)