04 enhancing ct for depression.pdf

8/17/2019 04 Enhancing CT for Depression.pdf

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n s t i t u t o d e C i e n c i a s C o n d u c t u a l C o n t e x t u a l e s y

T e r a p i a s I n t e g r a t i v

2 1 3

Enhancing Cognitive Therapy for Dep res sio n With Functional Analytic

Psychotherapy: Treatment Guidelines and Empirical Findings

R o b e r t J . K o h l e n b e r g , J o n a t h a n W . K a n t e r, M a d e l o n Y . B o l l in g ,

a n d C h a u n c e y R . P a r k er , U n i v e r s i t y o f W a s h i n g t o n

M avi s T sa i , Priv a te Prac t ice , Sea t t l e

Two enhancements to cognitive therapy ( C T )- -a broader rationale for the causes and treatment of depression, and a more intense

focus on the client-therapist relationship--were evaluated in a treatment development study. The enhancements were informed by

Func tiona l Analyti c Psychotherapy (FAP; tL J. Kohlenberg & Tsai, 1991), a treatment based on a behavioral analysis of the change

process. FAP Enha nced Cognitive Thera py (FEC T) includes 7 specific techniques that C T therapists can use to make their treatment

more powe rful a nd to address the diverse needs of clients more effectively. The results indicate that FE CT produced a greater ocus on

the client-therapist relationship and is a promising approach for improving outcome and interpersonal functio ning. It also appears

that a focus duri ng sessions on clients 'problematic cogn itions abou t the therapist adds to efficacy.

AVE YOU en co un ter ed cl ients who a re res i s tant to the

me t ho ds o f cogn i t i ve t he r apy (CT ) , i ns i s t ing t ha t

t he i r f ee l i ngs ru l e no ma t t e r wha t t hought s t hey have?

Have yo u eve r f e lt , whi l e do i ng CT , t ha t you w oul d l ike t o

focus mo re on t h e c l i en t - the r ap i s t r e l a t i onsh i p? Have you

e v e r w a n t e d t o m a k e y o u r t r e a t m e n t m o r e i n t e n se a n d i n -

t e rpe r sona l , so t ha t t he t he r apy r e l a t i onsh i p i t se l f is a p r i -

mar y veh i c le fo r c l i en t chan ge? I n t h i s a r ti c l e we desc r ibe

a t r e a t m e n t f o r d e p r e s s i o n t h a t e n h a n c e s C T s o t h a t it a d-

dres ses t he d i ve r se nee ds o f c l i en ts an d has wi de r appea l

f o r b o t h c l ie n t s a n d t h e ra p is t s. T h e e n h a n c e m e n t s w e r e

i n f o r m e d b y F u n c t i o n a l A n a l y ti c P s y c h o t h e r a p y ( FA P ;

R . J . Kohl enb erg & T sa i, 1991) , a t r ea t me nt b ased o n a be-

hav i ora l anal ys is o f t he p roces s o f t he r apeu t i c chang e .

P e rhap s t he expe r i ence o f Mr . G . , a c l i en t who r e -

c e iv e d b o t h C T a n d F A P - e n h a n c e d C T ( F E C T ), c a n b e s t

desc r i be t he qua l i t a t ive d i f f e r ence be t ween t he t wo ap-

proaches . M r . G . was a sub j ec t i n our t r ea t ment deve l op-

m e n t s t u d y w h o r e c e i v e d s t a n d a r d C T . W h e n , a f te r t h e

8 t h ses s i on , h i s t he r ap i s t exper i enced medi ca l p rob l ems ,

M r. G . swi t ched t o ano t he r t he r ap i s t ( co-au t hor Chaun cey

P arke r ) who used F E CT for t he r ema i n i ng 12 sess i ons .

Obvi ous l y t he r e i s cons i d e rab l e con fou ndi n g , b u t t h i s c li -

e n t w a s i n t h e u n i q u e p o s i t io n o f b e i n g a b l e t o d e s c ri b e

and c om par e h i s expe r i ence o f bo t h t r ea t ment s . M r. G ., a

44-yea r-o l d wi t h a l ong- s t an d i ng h i s t o ry o f ma j or depres -

s io n , h a d n o t r e s p o n d e d t o a v a r ie t y o f p r i o r m e d i c a t i o n s

a n d p s y c h o s o c i a l t r e a t m e n t s . A m o n g h i s p r e s e n t i n g

prob l e ms was a deep d i s sa ti s f act i on i n h i s i n t e rpe r so na l

Co g ni t i v e a nd Be ha v i o r a l Pr a ct i ce 9 , 2 1 3 - 2 2 9 , 2 0 0 2

1077-7229/02/213-22951.00/0

Copyright © 2002 by Association for Advanc ement of Behavior

Therapy. All r ights of rep roductio n in any form reserved.

r e l a t i onsh ips . He f e l t peo p l e r e j ec t ed h i m an d he was un-

ab l e t o ach i eve c l oseness w i t h o t he r s . Accord i ng t o Beck

Depres s i on Inven t ory (BDI ) s cores , he was no l onger de -

p r e s s e d a t t h e e n d o f o u r t r e a t m e n t , a n d r e p o r t e d m a k -

i ng p rogres s i n be i ng more i n t i ma t e wi t h h i s w i f e and

chi ldren. In this excerpt f rom the las t sess ion, Mr. G. de-

s c ri b es h o w h e e x p e r i e n c e d t h e t w o ty p e s o f t h e r a p y a n d

w h a t h e l e a r n e d :

T he re ' s a l o t o f s tu f f go i ng o n i n m y pe r sona l l i fe

t h a t w e ' v e b e e n w o r k i n g o n h e r e i n d e p r e s s i o n a n d

so on , and t ha t has l ed t o maybe t he cogn i t i ve t he r -

a p y w a y o f h a n d l i n g t h i n g s a n d l o o k i n g a t . . . , y o u

know, t he da i l y ac ti v it y l og and t hen do i n g t he

t h o u g h t r e c o r d s a n d a n a l y z i ng t h o u g h t s a n d h o w

t hey l ead t o t h i ngs . S o t ha t ' s ove r he r e [wi t h t he

f i rs t 8 s ess i ons o f CT ] . An d t h en on t h is o t h e r pa r t ,

whi ch I de f i n i t e l y go t i n t o wi t h you [ t he second 12

ses s ions o f F E CT ] , was i n my pe r sona l r e l a t i onsh i ps

and how t ha t works , on bo t h s i des , myse l f and t he

o t h e r p e r s o n . A n d t h e n i t b e c a m e h o w t h a t

o c c u r r e d f o r y o u a n d m e a s a n e x a m p l e o f [ m y

a p p e a r i n g t o o t h e r s a s] o m i n o u s . I t 's s o m e t h i n g I

l ea rne d w i t h you so t ha t i t woul d no t pe r s i s t i n

u n i n t e n t i o n a l l y c o l o r i n g m y r e l a t io n s h ip s .

M r . G . acknow l edges t he u t i l it y o f s t and ard CT , whi ch

he r ece i ved d i r ec t l y dur i ng t he f i r s t e i gh t s e s s i ons and i n

a m o d i f i e d f o r m d u r i n g t h e s e c o n d p h a s e o f t r e a t m e n t .

S econd , he s t a t e s t ha t dur i ng F E CT , he became aware , f o r

t he f i rs t t i me , o f an i n t e rpe r so na l p rob l em i nvo l v i ng

o t h e r s p e r c e i v i n g s o m e t h i n g o m i n o u s a b o u t h i m t h a t i n -

t e r f e r es w i t h h i s r e l a t i onsh i ps . T h i rd , he acknowl edges

t h a t th i s s a m e i n t e r p e r s o n a l p r o b l e m t h a t o c c u r r e d i n h is

da i l y l if e a l so occ ur r e d i n t he t he r apy ses s ion be t we en

hi m and h i s the r ap i s t . F i na l ly , he sugges t s t ha t l ea rn i ng t o




2/18



214 Ko h l e n b e r g e t a l .

d e a l w it h t h is p r o b l e m w i th t h e t h e r a p i s t w o u l d h e l p h i m

i n f u t u r e r e l a t i o n s h i p s wi t h o t h e r s .

T h e m e t h o d s a n d p r o c e d u r e s o f F E C T a r e d e s ig n e d t o

p r o d u c e t h e t y p e o f t h e r a p y e x p e r i e n c e t h a t t h is c l ie n t

d e s c r ib e s , c a p i t a l iz i n g b o t h o n t h e s t r e n g t h s o f C T a n d

o n t h e u s e o f t h e t h e r a p e u t i c r e l a t i o n s h i p a s a t o o l f o r i m -

p r o v i n g i n t e r p e r s o n a l r e l a t i o n s h i p s . D u r i n g t h i s t r e a t -

m e r i t d e v e l o p m e n t s tu d y, w e a l so g e n e r a t e d s t r at e g ie s f o r

t r a i n i n g c o g n i t i v e t h e r a p i s t s t o a d d FECT t o t h e i r r e p e r -

t o ir e s , a n d s o u g h t t o p r o v i d e a p r e l i m i n a r y a s s e s s m e n t o f

t h e e f f i ca c y o f F E C T c o m p a r e d t o s t a n d a r d C T . I n t h i s

a r t ic l e , w e d e s c r i b e F E C T t h e o r y a n d t e c h n i q u e s a n d

p r e s e n t f i n d i n g s f r o m t h e t r e a t m e n t d e v e l o p m e n t s tu d y

c o m p a r i n g F E C T t o s t a n d a r d C T .

FECT

T h e F E C T e n h a n c e m e n t s t o s t a n d a r d C T a r e i n -

t e n d e d t o b e u s e r - f r ie n d l y f o r e x p e r i e n c e d c o g n i ti v e t h e r-

a p i s ts , a n d r e l y u p o n t h e s k i l ls , t r a i n i n g , f o r m s , p r o c e -

d u r e s , a n d m e t h o d s o f CT . In p a r t i c u l a r , FECT wa s b u i l t

o n t h e f o u n d a t i o n o f A. T . Be c k , Ru s h , Sh a w, a n d Em e r y ' s

( 1 9 7 9) wi d e l y p r a c t i c e d a n d e m p i r i c a l l y v a l i d a t e d t r e a t -

m e n t f o r d e p r e s s i o n . T h e t wo m a j o r F E C T e n h a n c e -

m e n t s t o s t a n d a r d C T a r e ( a) t h e u s e o f a n e x p a n d e d r a -

t i o n a l e f o r t h e c a u s es a n d t r e a t m e n t o f d e p r e s s i o n a n d

( b ) a g r e a t e r u s e o f t h e c l i e n t - t h e r a p i s t r e l a t i o n s h i p a s a n

i n v i v o t e a c h i n g o p p o r t u n i t y .

E n h a n c e m e n t 1 : T h e E x p a n d e d R a t i o n a l e

T h e e x p a n d e d r a t i o n a l e is b a s e d o n t h e b e h a v i o r a l

v i ew o f c o g n i t i o n a n d i ts e m p h a s i s o n h i s t o r i c a l e x p l a n a -

t i o n s f o r c u r r e n t b e h a v i o r ( R . J . K o h l e n b e r g & Tsa i, 1 99 1 ,

c h a p t e r 5 ) . Co g n i t i o n i s d e f i n e d a s t h e a c t i v i ty o f t h i n k -

i n g, p l a n n i n g , b e l ie v i n g, a n d / o r c a t e g o r iz i n g . T h u s, c o g -

n i t i o n s , a l t h o u g h c o v e r t , a r e s i m p l y b e h a v i o r . Th i s c a st s

t h e o f t e n - m a d e d i s t i n c t i o n b e t we e n t h o u g h t s , f e e l i n g s ,

a n d b e h a v i o r, a n d t h e p r i m a c y o f t h e c o g n i t i o n - b e h a v i o r

r e l a t i o n s h i p , i n a n e w l i g h t : Th e r e l a t i o n s h i p b e t we e n

c o g n i t i o n a n d b e h a v i o r b e c o m e s a B e h a v i o r X - B e h a v i o r

Y r e l a t i o n s h i p , t h a t i s , a s e q u e n c e o f two b e h a v i o r s . He r e ,

Be h a v i o r X i s c o g n i t i o n a n d Be h a v i o r Y i s e x t e r n a l b e h a v -

i o r o r e m o t i o n a l r e s p o n s e . T h i s in t u r n a c c o m m o d a t e s a

v a r i e t y o f p o s s i b i l it i e s a s to t h e c a u s a l c o n n e c t i o n b e -

t w e e n c o g n i t i o n ( B e h a v i o r X ) a n d s u b s e q u e n t b e h a v i o r

( B e h a v i o r Y ). T h e d e g r e e o f c o n t r o l e x e r t e d b y c o g n i ti o n

o v e r s u b s e q u e n t b e h a v i o r is o n a c o n t i n u u m a n d v a ri es

d e p e n d i n g o n t h e p a r t i c u l a r c l i e n t' s h is to r y.

Th i s v ie w h a s i m p l i c a t i o n s f o r t h e n a t u r e o f t h e r a t i o -

n a l e t h a t i s p r e s e n t e d t o c l ie n t s in s t a n d a r d c o g n i t i v e

t h e r a p y f o r d e p r e s s i o n . F o r t h e p u r p o s e s o f th i s d i s c u s -

s i o n , t h e c o g n i t i v e h y p o t h e s i s i s r e p r e s e n t e d a s a n A- B-C

s e q u e n c e i n wh i c h A r e p r e s e n t s a n e v e n t o r s t i m u l u s , B

r e p r e s e n t s c o g n i t i o n i n r e s p o n s e t o A , a n d C r e p r e s e n t s

(a) A r - - > B , > C

b) A i > C

B

(c) A

C

Figure 1. Some cognit ion-behavior relat ionships according to

the FECTexp and ed rationale. A = An tece den t Event; B = Belief/

Cognit ion; C = Consequence (emotional react ion). (a) Repre-

sents the standard cognitive model. (b) Represents a situation in

which there is no cognition. (c) Represents a situation in which

cognition precedes but is not causally related to the reaction.

t h e r e s u l t i n g b e h a v i o r o r e m o t i o n a l r e s p o n s e ( A . T . Be c k ,

1967, p . 322) . Thi s i s i l lus t ra ted in Figu re 1 (a ) . Both CT

a n d F E C T t h e r a p i s t s p r e s e n t t h i s s t a n d a r d c o g n i t i v e h y -

p o t h e s i s a n d t e l l c l i e n t s t h a t t h e i r b e l i e f s , a t t i t u d e s , a n d

t h o u g h t s a b o u t e x t e r n a l e v e n t s le a d t o p r o b l e m a t i c f e e l -

i n g s a n d m a l a d a p t i v e b e h a v i o r : t FECT t h e r a p i s t s , h o w-

e v er , t e l l c li e n t s t h a t o t h e r p o s s i b i l i ti e s m i g h t a l s o e x i s t in

a d d i t i o n t o t h e A- B- C p a r a d i g m . Fo r e x a m p l e , F i g u r e 1 ( b )

r e p r e s e n t s t h e c l i e n t wh o s ay s, "I j u s t r e a c t e d , I d i d n ' t

h a v e a n y p r e c e d i n g t h o u g h t s o r b e l i e f s . " I n t h i s c a s e , t h e

F E C T t h e r a p i s t is m o r e a c c e p t i n g o f t h e i d e a t h a t t h e r e i s

n o c o g n i t i o n a t wo rk . F i g u r e 1 ( c) r e p r e s e n t s y e t a d i f f e r e n t

c l i e n t wh o s ay s , " I t r u l y b e l i e v e t h a t I d o n o t h a v e t o b e

per fe c t , b ut I s t i ll f ee l l ike I have to be ." In th i s case , the

F E C T m o d e l a c c o m m o d a t e s t h e p o s s i b il i ty t h a t t h e c l i e n t

m a y h a v e a " B" t h a t d o e s n o t p l a y a r o l e i n c a u s i n g t h e

p r o b l e m a t i c " C , " e v e n t h o u g h t h e r e i s a t e m p o r a l s e-

q u e n c i n g t h a t r e s e m b l e s th e o n e p o s i t e d i n th e c o g n i t iv e

h y p o t h e s i s . T h a t i s, t h e FECT v i ew i s th a t i t is p o s s i b l e t o

h a v e a b e l i e f t h a t p r e c e d e s t h e p r o b l e m a t i c e m o t i o n

a n d / o r b e h a v i o r b u t i s n o t c a u s a ll y r e l a t ed . T h e r e a r e

s e v e r a l o t h e r v a r i a t i o n s o f t h e A- B- C p a r a d i g m t h a t m i g h t

a l s o h a v e b e e n i n c l u d e d i n F i g u r e 1 . Fo r e x a m p l e , A- C- B

w o u l d r e p r e s e n t a c l i en t w h o r e a ct s a n d t h e n h a s a

t h o u g h t . Fo r c l i e n t s wh o s e e x p e r i e n c e m a t c h e s A- B- C a s

s h o w n i n F i g u r e 1 ( a ), F E C T p r o p o s e s t h a t t h e m e t h o d s

o f c o g n i t iv e t h e r a p y wo u l d b e m a x i m a l l y e f f e ct i v e a n d

s h o u l d b e u s e d . H o w e v e r, f o r c l ie n t s w h o s e e x p e r i e n c e

1Technically, the term ognition refers to cognitive products, struc-

tures, or processes (Hollon & K~iss, 1984). Due to space limitations,

we have not made this distinction h ere, bu t we have shown elsewhere

that ou r analysis is consistent with the mor e technical m eanings o f

cognition (Kohlenberg & Tsai, 1991, cha pte r 5).




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E nhanc i ng

Cognitive Therapy

215

c o r r e s p o n d s t o o n e o f t h e o t h e r p a r a d i g m s s h o w n i n Fi g-

ure 1 , s t anda rd cogn i t i ve t he r apy m i gh t r e su l t in a c li en t -

t he r apy mi sm at ch and a l es s e f f ect i ve t r ea t ment . I t is a l so

poss i b l e t ha t mul t i p l e pa r ad i gms ex i s t f o r a g i ven c l i en t ,

o r t ha t pa r ad i gms change f rom s i t ua t i on t o s i t ua t i on .

T he use o f t he ex pa nd ed r a t i ona l e i s i l l ust r a t ed i n t he

case o f a c l i en t, M r . D . Mr . D . had a p rob l em of ge t t i ng

angry t oo eas ily . He b rou gh t up an exam pl e o f ge t t i ng an-

gry a t o t he r d r i ve rs a t a f our -way s t op whi l e d r i v i ng t o h i s

a p p o i n t m e n t . H e e x p l a i n e d h o w t h e d r i v e r i n f r o n t o f

h i m cou l d have m ove d fo rward a l it t le and a l l owed M r. D .

t o make a r i gh t -hand t u rn . I n t h i s exampl e , t he t he r ap i s t

does a b r i e f a s ses sment t o d e t e rm i ne i f A-B-C or an a l te r -

na t e pa r ad i g m sh oul d a l so be con s i de re d i n M r. D . ' s

t r e a t m e n t :

MR. D. : I tho ugh t , "You idiot "

T HE RAPIST : You r em em be r dur i ng our d i scuss i on o f

t h e [ F E C T ] b r o c h u r e t h a t t h o u g h t s o m e t i m e s

precedes f ee l i ngs bu t can a l so occur a f t e r . A t t he

four -way s t op , you t houg ht , "You i d io t " W ere you

a w a re a s to w h e t h e r y o u h a d t h a t t h o u g h t f ir st a n d

t hen go t angry , o r d i d you ge t angry f i r s t and t hen

h a v e t h e t h o u g h t ?

MR. D.: I got angry first .

A l t hough t he s t andard cogn i t i ve hypot hes i s s t a t e s t ha t

d e p r e s s o g e n i c s c h e m a s a c q u i r e d d e v e l o p m e n t a l l y c r e a t e

a vu l ne rab i l i ty t o depres s i on , t he F E CT exp and ed r a t io -

na l e i nc r eases t he emphas i s on h i s t o r i ca l f ac t o r s more

broad l y de f i ned , t o acco unt fo r t he c l ien t ' s reac t i ons t o

the wor ld ei ther a long wi th o r as an al ternat ive to the A-B-C

hypothesis . This i s consis tent wi th a behavioral analys is of

prob l em s , t r ac i ng causa l i ty t o ex t e rna l sources oc cur r i n g

i n t he r e i n fo rcem ent h i s t o ry o f t he i nd i v i dua l (R . J .

K o h l e n b e r g & Ts ai , 1 9 91 ) . A l t h o u g h c h a n g i n g c o g n i t i o n s

is of ten a successful therapeut ic s t ra tegy, i t i s somet imes

adva n t ageo us t o t ake an h i s t o r i ca l v iew of how t he p rob-

l e m d e v e l o p e d . R e c o g n i z i n g h i st o ri c a l a n t e c e d e n t s t h a t

a c c o u n t f o r c li e n ts ' p r o b l e m s a n d t h e i r n e g a ti v e c o g n i -

t i ons g ives t hem a way t o exp l a i n t he i r beh av i or t o t he m-

se lves t ha t ma y be l es s b l am i ng t han cogn i t i ve exp l ana -

t ions by themselves .

T h e e x p a n d e d r a t i o n a le i s e x p e c t e d t o i m p r o v e t h e

m a t c h b e t w e e n c l ie n t a n d t r e a tm e n t . A s r e c e n t ly p o i n t e d

ou t i n t h i s j ou rna l (Addi s & Carpen t e r , 2000) , c l i en ts who

r e s p o n d f a v o ra b l y t o t h e t r e a t m e n t r a t io n a l e i n C T f o r

depres s i o n a r e m ore l ike l y t o i mprove fo l l owi ng tr ea t-

m e n t ( A d d is 1 9 9 5 / 1 9 9 6 ; A d d i s & J a c o b s o n , 1 9 96 ; F e n n e l

& T easda le , 1987 ; T easda l e, 1985) . Addi s and C arpe n t e r

h y p o t h e s i z e t h a t t h e m a t c h b e t w e e n t h e c l i e n t a n d t h e

t r e a t m e n t r a t i o n a l e p r o m o t e s m o r e f a v o r a b l e o u t c o m e

due t o such f ac t o r s as i nc r eased r appo r t , t he r apeu t i c a ll i-

a n c e , a n d w i l l i n g n e s s t o d o h o m e w o r k . O n t h e o t h e r

hand , a mi smat ch can have de l e t e r i ous e f f ec t s . F or exam-

p i e, i n c o m p a r a t i v e o u t c o m e s t u d i es i t i s n o t u n c o m m o n

f o r a p e r c e n t a g e o f cl ie n ts t o d r o p o u t o f t r e a t m e n t b e -

c a u s e t h e y f e el m i s m a t c h e d t o t h e a s s ig n e d t r e a t m e n t

(Addis , 1995 / 1996 ) . Addi s a l so r ep or t e d t ha t mi smat c hes

d u r i n g C T f o r d e p r e s si o n m o s t o f te n o c c u r r e d b e c a u s e

t he CT r a t i ona l e d i d no t addres s t he pa t i en t ' s des i r e t o

v i ew t he i r p rob l ems as t he r e su l t o f h i s t o ry and exper i -

ence. S imi lar ly, Castonguay, Goldfr ied, Wiser , Raue, and

Hayes (1996) fou nd t ha t when t he r ap i s t s pe r s i s t ed i n the

app l i ca t i on o f cogn i t i ve t echn i qu es desp i t e c l i en t s ' s t a te -

m e n t s t h a t t h e m o d e l w as n o t a p p r o p r i a t e , t h e t h e r a p e u -

t ic a l l i a n c e - - a n d t r e a t m e n t o u t c o m e s - - s u f f e r e d . T h u s ,

t h e F E C T e x p a n d e d r a t io n a l e is e x p e c t e d t o e n h a n c e

out con l e .

Enhancemen t 2: A Greater Use of the

Client-Therapist Relationship

In FECT, the c l ient - therapis t re la t ionship i s seen as a

soc i a l env i ronment w i t h t he po t en t i a l t o evoke and

cha nge ac t ua l i ns t ances o f t he c l i en t 's p rob l em at i c behav -

i o r i n t he he re and now (F o ll e t te , Naugl e , & Ca l l aghan ,

1996; R . J . Koh l enb erg & T sai , 1991) . F or examp l e , a c li -

en t who d oes n ' t expres s an ger i n h i s dai l y l if e becau se h e

as sumes t e r r i b le t h i ngs wil l hap pen i f he does , m i gh t g e t

angry a t t he t he r ap i s t bu t no t expres s t h i s anger because

of h is a s sumpt i on . I n F AP te rmi no l ogy , t he c l i en t ' s a s-

sumpt i on abou t t he t he r ap i s t i s r e f e r r ed t o a s C l i n i ca l l y

Re l evan t Behav i or (CRB) , an ac t ua l he r e - and-now occur -

r ence , i n t he t h e r apy ses s ion , o f da i ly l if e p rob l em at i c

t h i nk i ng o r behav i or . Accord i ng t o F AP t heory , t he r e a r e

e x t r a o r d i n a r y o p p o r t u n i t i e s f o r s i g ni f ic a n t, t h e r a p e u t i c

c h a n g e w h e n C R B s o c c u r a n d a r e r e c o g n i z e d b y t h e t h e r-

ap is t . T he t he r ap i s t wh o no t i ces CR B wi ll be mo re l i kel y

t o s h a p e i m m e d i a te l y , e n c o u r a g e , a n d n u r t u r e i m p r o v e -

men t s i n v ivo (R . J . Ko hl en berg & T sai , 1991, chap t e r 2 ) .

Accord i ng l y , s eve ra l spec i f i c F E CT t echn i ques a r e de -

s i gned t o i nc r ease t he r ap i s t awareness o f CRBs . It shou l d

be no t ed t ha t CRBs a r e r ea l, t hey occur na t u r a l l y dur i n g

t h e ra p y , a n d t h e y d i f fe r f r o m t h e p r o m p t e d a n d / o r

sc r i p t ed wi t h i n - ses s i on beh av i or s o f r o le -p l ay i ng , behav-

ioral rehearsal , or social skil ls t ra ining (R. J . Koh len ber g,

Tsai , & Dougher , 1993) .

T he F E CT use o f t he c l i en t - the r ap i s t r e l a t i onsh i p a s an

i n v ivo l ea rn i ng opp or t u n i t y is based on a we ll -known

p r o p e r t y o f r e i n f o r c e m e n t : T h e c l o s e r in t i m e a n d p l a c e

a behav i or i s t o i t s consequences , t he g r ea t e r w i l l be t he

e f f ec t o f t hose co nsequ ences . I t fo l lows , t hen , t ha t t r ea t -

me nt e f f ec t s w il l be s t ro nger i f c l i en t s ' p rob l em behav i or s

a n d i m p r o v e m e n t s o c c u r d u r i n g t h e s e s s i o n , a s t h e y a r e

c l osest i n t i me and p l ace t o t he ava il ab le r e i n forc eme nt

f rom t he t he r ap i s t . Ra t he r t han on l y t a l k i ng abou t t he c li -

en t ' s p rob l ems , t he t he r ap i s t can e f f ec t pos i ti ve chang e as

behav i or s occur . Gol df r i ed (1985) desc r i bed t hese spe -

c i a l oppor t un i t i e s a s " i n v i vo" cogn i t i ve behav i ora l work




4/18



2.16 Kohlenberg et a l .

a n d n o t e d t h a t si t ua t io n s w h e n t h e s e o p p o r t u n i t i e s o c c u r

a r e " m o r e p o w e r f u l t h a n i m a g i n e d o r d e s c r i b e d " s i t u a -

t i ons (p . 71) . T he same i dea i s f ou nd i n t he wi de l y ac -

c e p t e d n o t i o n t h a t in v iv o e x p o s u r e t r e a t m e n t is m o r e

powe r fu l t han i n -off i ce t rea t men t . T h i s F AP v i ew of the

c l i en t - t he r ap i s t r e l a t i onsh i p d i f f e r s bo t h f rom t he no t i on

o f c o ll a b o r a t i o n i n c o g n i t iv e t h e r a p y a n d f r o m t h e r a p e u -

t ic a l l iance (Cal lagh an, N augle , & Fol le t te , 1996; Fol le t te

et a l . , 1996; B. S . Kohlenberg, Yeater , & Kohlenberg,

1998) . A l t h oug h t he re a r e t hnd am ent a l t heore t i ca l d i f-

f e r ences be t ween F AP and psychoana l ys is ( s ee R . J .

Koh l enb erg & T sai , 1991 , chap t e r 7 ) , t he no t i on o f CRBs

a s s p e ci a l o p p o r t u n i t i e s f o r th e r a p e u t i c c h a n g e h a s m u c h

i n c o m m o n w i t h t h e p s y c h o a n a ly t i c c o n c e p t o f w o r k i n g

wi t h t r ans f e r ence (R . J . Kohl enb erg & T sa i, 1994) .

The Two M ain Forms o f Cl inica lly Relevant Behavior:

CRB1 and CRB2

T h e u s e o f t h e t h e r a p e u t i c r e l a t io n s h i p d e p e n d s o n

t he t he r ap i s t ' s ab i l i t y t o r ecogni ze t he c l i en t ' s p rob l ems

as t hey occur i n s es s i on . S uch p rob l emat i c behav i or i s

t e rm ed CRB1. E qua l l y i mp or t an t i s t he t he r ap i s t ' s ab i l it y

t o r ecogni ze i mprovement s a s t hey occur i n - ses s i on .

T h e s e i m p r o v e m e n t s a r e t e r m e d C R B 2 .

Problematic C ognit ive and Interpersonal Behaviors

as CRBs

C R B l s a n d C R B 2 s ( p r o b l e m s a n d i m p r o v e m e n t s i n

t h e h e r e a n d n o w ) m a y b e c o g n it i ve b e h a v i o r a n d / o r i n-

terpersonal behavioi : Cogni t ive CRBs are in-sess ion, ac-

t ua l occu r r enc es o f p rob l e mat i c c ogn i t i on ( t h i nk i ng , a s-

sumi ng , be l i ev ing , pe r ce i v i ng) . I n t he e xam pl e o f Mr. D .,

t he ang ry c li en t, t he c l i en t 's a s sump t i on t ha t " t he t he r a -

p i s t w il l do som et h i n g t e r r i b le i f I expres s my anger " is a

p r o b l e m a t i c i n -s e ss i on c o g n i t i o n . T h e o c c u r r e n c e o f a

prob l emat i c cogn i t i ve CRB prov i des a spec i al oppo r t u -

n i t y fo r t he t he r ap i s t t o do i n v i vo CT . F or examp l e , t he

t he rap i s t cou l d use a t ho ugh t l og o r empi r i ca l hypo t hes i s -

t e s t i ng pe r t a i n i ng t o t he he re - and-n ow c l i en t - t he r ap i s t in -

t e r ac t i on . Cogni t i ve CRBs a r e a l so i den t i f i ed a s hav i ng

spec i a l s i gn i fi cance i n t he CT va r i an ts o f Youn g (1990)

and S af r an and S ega l ( 1990) .

T he ang l y c l i en t exam pl e i nvo l ved bo t h cogn i t i ve and

i n t e r p e r s o n a l C R B s. I n t e r p e r s o n a l C R B s a r e a c t u a l i n -

ses s i on p rob l emat i c i n t e rpe r sona l behav i or . One CRB1

may have been t ha t t he c l i en t d i d no t expres s h i s angry

fee l ings t oward t he t he r ap i s t . T he t he r ap i s t cou l d have en-

couraged o r p rompt ed t he c l i en t t o expres s h i s anger i n -

s t ead o f emp l oy i ng t he i n v ivo cogn i t i ve i n t e rven t i on ( e .g . ,

t he t h ou gh t l og) i f such expres s i on i s concep t ua l i zed as a

CRB2, o r i mprovement i n c l i en t behav i or . T h i s po i n t s up

t he i mp or t ance o f genera t i ng a c l ea r case concep t ua l iza t i on

f rom t he ou t se t and upda t i ng i t a s tr ea t ment p rogres ses .

(Case concep t ua l i za t i on i s ou t l i ned be l ow. )

General izat ion From Treatment to Dai ly Life

As t he rapy p rogres ses , c l i en t s d i sp l ay more CRB2s ( i m-

prove men t s i n s es s i on) . As d i scussed in R . J . Ko hl en berg

and T sai ( 1991), gene ra l i za t i on o f i mpr ovem ent s f rom

t he c l i en t - t he r ap i s t i n t e r ac t i on t o da i ly li fe is expec t ed t o

o c c u r n a t u r a ll y b u t c a n b e a u g m e n t e d b y o ff e r i n g in t er -

p r e t a t i ons t ha t compare wi t h i n - ses s i on i n t e r ac t i ons t o

dai ly l ife . For exa mple , the th erapis t m igh t say, "Your be-

l ief that I wi ll do so me thi ng ter r ible to you i f you cr i t ic ize

t h e t h e r a p y s e e m s t o r e s e m b l e t h e b e l i e f y o u h a v e a b o u t

others in your l i fe ." Successful wi thin-sess ion hypothesis

t e s t i n g a n d c o n s e q u e n t m o o d i m p r o v e m e n t w o u l d s i m i -

l a rl y be r e l a t ed t o uses in da i l y l if e . S t andard CT ho me -

work as s i gnmen t s can be bu i l t f r om t h is i n v ivo work . F or

exampl e , t he t he r ap i s t m ay say, "Now t ha t you have fou nd

t h a t y o u r b e l i e f - - t h a t I w ill r e s p o n d p o o r l y t o y o u i f y o u

expres s you r f ee l i ngs d i r ec t l y t o me- - i s i naccura t e , d o

y o u t h i n k a g o o d h o m e w o r k a s s i g n m e n t w o u l d b e t o

check ou t t ha t be l i e f w i th you r w if e?"

Putt ing the Enhancem ents Into Pract ice:

Seven Speci f ic Techniques

IYea t m ent oc cur s s i mul t aneou s l y o n t wo level s. A t t he

f i rst level, FECT thera pis t s co nd uc t A. T . Beck an d col -

l eagues ' ( 1979) CT for depres s i on . Beck ' s CT consi s t s o f

a 20-ses si on s truc t u r e and spec if i c p roc edu res such as ( a )

de f i n i ng and se t t i ng goa l s , ( b ) s t nmt ur i ng t he ses s i on

( se t ti ng and fo l l owi ng an agenda ; e l i c i ti ng f eedback f rom

t he c l i en t a t the en d o f t he ses s i on) , ( c ) p r esen t i n g a r a -

t i ona l e, an d (d ) us i ng cogn i t i ve -behav i ora l s tr a t eg ies and

t echn i ques . T he F E CT t he rap i s t , however , uses t he ex-

p a n d e d r a t io n a l e r a t h e r t h a n t h e s t a n d a r d C T r a ti o n a le .

T h i s r equ i r es t he f l ex i b il i ty t o d ro p t he A-B-C hypot hes i s

i f i t d o e s n o t m a t c h t h e c l i en t 's e x p e r i e n c e a n d / o r i f t h e

cl ient i s not progress ing.

T he seco nd l eve l o f t he r apy i s pe rha ps t he mo s t i m-

por t an t . A t t he same t i me t ha t t he above t echn i ca l p roce -

dures a r e used , F E CT t he rap i s t s a r e obse rv i ng t he c l i en t -

t he r ap i s t i n t e r ac t i on and l ook i ng fo r t he c l i en t 's da i ly li fe

p r o b l e m s a n d d y s f u n c t io n a l t h o u g h t s a c t ua l ly o c c u r r i n g

i n t h e h e r e a n d n o w , w i t h i n t h e c o n t e x t o f th e c l i e n t -

t he r ap i s t r e l a t i onsh i p . T he fo l l owi ng seven t echn i qu es

h i g h l i g h t th e F E C T a p p r o a c h a n d h e l p t h e t h e r a p i s t to

work on both levels .

1. Setting the Scene Early

T he F E CT i n t e r es t i n h i s to ry and obse rva t i on o f i n

vivo cl ient beh avio r i s es tabl i she d early. Ei the r befo re

t reat me nt begins o r dur ing the f i rs t sess ion of FECT, cli -

ents are given the fol lowing ass ignmen t : "Wri te an o ut l ine,

a t ime cha r t , o r an au t o b i ogr aphy of t he ma i n even t s , en -

dur i ng c i r cums t ances , h i gh l i gh t s , t u rn i ng po i n t s , and r e -

l a t i onsh i ps t ha t have shaped who you a r e a s a pe r son ,

f r o m y o u r b i rt h t o th e p r e s e n t t im e . " T h e a s s i g n m e n t




5/18



E nhanc i ng Cogni t i ve T herapy 217

i nd i ca t es t o t he c l i en t t ha t t he t he r ap i s t i s i n t e r es t ed i n

h i s to ry . A t ano t he r l eve l, i t gi ves t he t he r ap i s t an opp or t u -

ni ty to observe how the cl ient deals wi th this task (e .g. ,

p roc ras t i na t es , g i ves spa r se i n form at i on , comp l e t es vo l -

um es o f wr i t ings , asser t ively refuses to do i t ) and helps

g e n e r a t e h y p o t h e s e s a b o u t p o t e n t i a l C R B s t h a t m i g h t a p -

pea r i n t he r apy . Bot h t he h i s t o r i ca l i n fo rmat i on and t he

h y p o t h e s i z e d C R B s e n t e r i n t o t h e f o r m u l a t i o n o f a n i ni -

t ia l case concep t ua l i za t i on as desc r i bed be low.

2. P r e s e n t t h e E x p a n d e d R a t i o n a l e a n d E l i c it F e e d b a ck

U n d e r s c o r i n g F E C T ' s i n cl u s i o n o f C T , th e t h e r a p is t

p r esen t s a t r ea t ment r a t i ona l e t o t he c l i en t i n t he fo rm of

t wo broch ures , t he Beck Ins t i t u t e 's "Cop i ng W i t h Depres -

s i on" (A . T . Beck & Gree nberg , 1995) and t he F E CT bro-

chu re (R . J . Koh l en ber g & T sai , 1997) . "Co pi ng W i t h

Depres s i on" p r esen t s t he cogn i t i ve hypot hes i s , a p r e l i mi -

n a r y o u d i n e o f t y p es o f t h i n k i n g e r r o r s d e p r e s s e d p e o p l e

c o m m o n l y m a k e , a n d a b r ie f o v er v ie w o f th e d i r e c t i o n o f

t r e a t m e n t . T h e F E C T b r o c h u r e a c k n o w l e d g e s t h e A- B- C

hypot hes i s and t he va l ue o f l ea rn i ng new ways t o t h i nk . I t

a l so allows for the poss ibi l i ty that th e A-B-C pa rad igm

mi g ht no t a l ways ma t ch t he p a r t i cu l a r c l i en t ' s expe r i ence

and d i scusses a l t e rna ti ve pa rad i gm s . F or examp l e , t he

brochure s t a t e s ,

T h e f o c u s o f y o u r t h e r a p y w i ll d e p e n d o n t h e

causes o f you r p rob l ems . T hus , a l ong wi t h cogn i t i ve

t he rapy , your t r ea t ment mi gh t a l so i nc l ude : exp l or -

i n g y o u r s t re n g t h s a n d s e e i n g t h e b e s t o f w h o y o u

are ; g r i ev i ng your l os ses , con t ac t i ng your f ee l i ngs ,

e spec ia l l y t hose t h a t a r e d i f f icu l t f o r you t o exper i -

ence ; deve l op i ng r e l a t i onsh i p sk i l l s ; deve l op i ng

mi ndfu l nes s , accep t ance and an obse rv i ng se l f ;

ga i n i ng a s ense o f mas t e ry i n your l i fe .

T h e F E C T b r o c h u r e e m p h a s i z e s f o c u s in g o n t h e h e r e

and n ow and us i ng t he c l i en t - t he r ap is t r e l a t i onsh i p t o

l ea rn new pa t t e rns o f behav i or . A more d e t a i l ed desc r i p -

t i o n o f th e F E C T r a t i o n a le c a n b e f o u n d i n R . J . K o h l e n -

be rg and T sai ( 2000) .

P resen t i ng t he r a t i ona l e is a c ri t ica l j un c t u re i n t he r -

a p y a n d m u s t b e a c c o m p a n i e d b y t h e r a p i st o b s e r v a t io n o f

how t he r a t i ona l e i s r ece i ved by t he c l i en t , wha t pa r t s o f i t

e l ic i t pa r t i cu l a r en t hus i asm , o r wha t pa r t s e l i c i t some d i s-

agreement . Because t he F E CT expanded r a t i ona l e i s f l ex-

i b le , c l ien t f eedback i s i mp or t a n t t o he l p de t e rmi n e t he

cour se o f t he r apy o r t he pa r t i cu l a r t ype o f in t e rven t i ons

t o be used . A t t he same t i me , a l l c l i en t r eac t i ons a r e

v i ewed as po t en t i a l CRBs. F or exam pl e , a f emal e c l i en t

may say, "That ' s f ine, whatever ," in react ion to the bro-

chures . W ha t ' s g o i ng on i n t h i s case? I s t h is t he way t he

c l i en t dea ls w i th o t he r s , a s we l l - - a cce p t i n g wha t eve r is

d i shed ou t ? I s she a f r a i d t o expres s he r r ea l r eac t i on t o

the therapis t , jus t as she i s wi th others? Or i s thi s par t icu-

l a r r e sponse no t an i ns t ance o f t he c l i en t ' s da i l y l if e p rob-

l ems? T hi s p roces s o f no t i c i ng po t en t i a l CRBs is e s sen t i a l

t o F E CT , and is sha r pen ed by the use o f t he case concep -

t ua l i za t i on fo rm as d iscussed be l ow.

3 . U s e C a s e C o n c e p t u a l i z a t i o n a s a n A i d

t o D e t e c t i n g C R B

In F ECT , case concep t ua l i za t i on i s t he s i ne qua non of

t he rap eu t i c work . I t i s i n f ac t a f unc t i ona l ana lys i s o f r el e -

van t c li en t behav i or s ( t h i nk i ng and f ee l i ng i n add i t i on t o

phys i ca l and ve rba l even t s ) . As d i scussed i n R . J . Kohl en-

be rg an d T sai ( 2000) , F E CT case concep t u a l i za t i on se rves

t h r ee p urposes . F i rs t, it gene ra t e s an ac cou nt o f how t he

c l i en t ' s h i s t o ry r e su l t ed i n t he cu r r en t da i l y l if e p rob l ems .

I t i n c l u d e s a n e x p l a n a t i o n o f h o w c u r r e n t p r o b l e m b e -

hav i or s were adap t i ve a t t he t i me t hey were acqu i r ed , and

se ts t he scen e fo r t h e c l i en t t o l ea rn new ways o f behav-

i ng . S econd , i t i den t i f i e s poss i b l e cogn i t i ve phenomena

t h a t m i g h t b e r e la t e d t o c u r r e n t p r o b l e m s . T h i r d , a n d

mos t i mpor t an t l y , F E CT case concep t ua l i za t i on i den t i f i e s

and p red i c t s how c l i n i ca l l y r e l evan t behav i or - -da i l y l i f e

p r o b l e m s ( i n c l u d i n g d y s f u n c ti o n a l th i n k i n g ; C R B 1) a n d

i m p r o v e m e n t s ( C R B 2 ) - - m i g h t o c c u r d u r i n g t h e s e ss io n

wi t h i n t he c l i en t - t he r ap i s t r e l a t i onsh i p . Hence , t he case

conc ep t ua l i z a t i on h e l ps t he r ap i s ts no t i ce CRBs as t hey

o c c u r a n d t o u s e t h e se o p p o r t u n i t i e s t o sh a p e a n d r e i n -

fo r ce i mprovement s i n v i vo .

T h e F E C T c a s e c o n c e p t u a l i z a t i o n f o r m i s a w o r k i n g

d o c u m e n t t o h e l p m a i n t a i n a fo c u s o n t h e g o a l s o f t h e r-

apy and i nc r ease t he r ap i s t d e t ec t i on o f in - sess i on p rob-

l e m a t i c t h i n k i n g a n d b e h a v i o r a n d t h e i r i m p r o v e m e n t s .

T he fo rm i s f i ll ed ou t a s soon as t he r e i s en ou gh i n forma -

t i on . S ome t i mes i t i s f i ll ed ou t j o i n t l y w i t h t he c l i e n t - - a t

t he ve ry l eas t , i t i s p r esen t ed t o t he c l i en t f o r f eedback ,

a n d m o d i f i e d t h r o u g h o u t t h e c o u r s e o f t h e r a p y a s m o r e

i n f o r m a t i o n is g a th e r e d . A m o r e d e t a i le d d e s c r i p t io n o f

t h is f o rm an d i ts app l i ca t i on can be fou nd i n R . J . Kohl en-

be rg and T sai ( 2000) . A desc r i p t i on o f t he fo rm ' s s i x co l -

um ns fo ll ows.

Daily life problems.

T hese a r e t he c l i en t ' s compl a i n t s .

F or exam pl e , M r. G . comp l a i ne d o f a l ack o f c l ose r el a -

t i onsh i ps an d r e j ec t i on by o t he r s .

Relevant history.

Hi s t o ry r e f e r s t o ch i l dhood and s i gn i f -

i can t even ts ove r t he li fe span , o r mo re r e cen t e xper i ences

t h a t a c c o u n t f o r t h e t h i n k in g , a c t i on s , a n d m e a n i n g t h a t

may be i mpl i ca t ed i n da il y l if e p rob l ems . T he purp ose o f

t h is co l um n i s t o genera t e an exp l a na t i on o f how t he cur -

r e n t p r o b l e m s w e r e l e a r n e d a n d h o w t h e y w e re a d a p t iv e

a t the t i me t hey were acqu i r ed . H i s t o r ica l i n t e rp re t a t i ons

se t t he scene f o r t he c l i en t t o l ea rn n ew ways o f behav i ng .

F or exampl e , M r . G . r epo r t ed a f ami l y env i ron me nt t ha t

seve re l y pun i shed warm t h and vu l nerab il it y .

Corresponding in-session problems (interpersonal/behavioral

CRBls).

I t was hypot hes i ze d t ha t M r . G . woul d ac t i n ways




6/18



2 1 8 K o h l e n b e r g e t a l.

t h a t w o u l d i n t e r f e r e w i t h f o r m i n g a c l o s e r e l a t i o n s h i p

w i t h t h e t h e r a p i s t . I t w a s in t h i s c o n t e x t t h a t M I : G . 's " o m -

i n o u s " s t yl e o f i n t e r a c t i n g w a s i d e n t i f i e d b y t h e t h e r a p i s t .

T h i s s ty le e m e r g e d w h e n t h e t h e r a p i s t w as o p e n a n d e x -

p r e s s e d w a r m t h t o w a r d M r . G .

Corresponding cognitive concepts (cognitive CRBls: auto-

matic thoughts, core beliefs, under lying a ssumptions ).

Mr. G.

h a d t h e c o r e b e l i e f t h a t h e w a s de f e c t iv e .

Daily life goals, M E G . ' s g o a l s w e r e t o b e l e s s d e p r e s s e d

a n d t o h a v e m o r e i n t i m a c y i n h i s r e l a t i on s h i p s .

In-session goals (CRB2s). T h e s e a r e i m p r o v e m e n t s i n

t h e c l i e n t - t h e r a p i s t r e l a t i o n s h i p . M r . G . , f o r e x a m p l e ,

d e m o n s t r a t e d i m p r o v e m e n t b y b e i n g v u l n e r a b l e w h e n

h e s a i d, " I d o n ' t w a n t t o a p p e a r o m i n o u s n o w ," a f te r t h e

t h e r a p i s t t o l d h i m t h a t h e c a r e d a b o u t a n d l i k e d M r . G .

T h e t h e r a p i s t a c k n o w l e d g e d t h e i m p r o v e m e n t a n d c o n -

f i r m e d t h a t t h e i r r e l a t i o n s h i p h a d b e e n s t r e n g t h e n e d b e -

c a u s e o f M r. G . ' s C R B 2 . H y p o t h e s i z i n g i n a d v a n c e o n t h e

c a s e c o n c e p t u a l i z a t i o n f o r m a b o u t C R B 2 s t h a t m i g h t o c -

c u r h e l p s t h e t h e r a p i s t t o b e p r e p a r e d f o r t h e ir e m e r -

g e n c e a n d t o be i n a b e t t e r p o s i t i o n t o n u r t u r e a n d s h a p e

t h e i m p r o v e d i n t e r p e r s o n a l b e h a v i o r i f a n d w h e n i t

d o e s h a p p e n .

p r e s e n t s s e v e r a l c o r e b e l i e f s i d e n t i f i e d b y J . S . Be c k

( 1 9 9 5) , a l o n g w i th c o r r e s p o n d i n g C R B s t h a t c a n b e a nt i c -

i p a t e d f r o m t h e m .

Intimacy CRBs. A t t h e b e g i n n i n g o f t h e r ap y , F E C T

t h e r a p i s t s t e l l t h e i r c l i e n t s t h a t w h e n t h e y c a n e x p r e s s

t h e i r t h o u g h t s , f e e l i n g s , a n d d e s i r e s i n a n a u t h e n t i c , c a r -

i n g , a n d a s s e r t i v e w ay , t h e y w il l b e m o r e l i k e l y t o f i n d j o y

i n li f e a n d t o b e le ss d e p r e s s e d . T h e t h e r a p y r e l a t i o n s h i p

p r o v i d e s a u n i q u e o p p o r t u n i t y t o b u i l d t h e s e s k il ls be -

c a u s e t h e t h e r a p i s t c a n o f f e r t h e c l i e n t s o m e t h i n g t h a t n o

o n e e l se c a n i n t h e s a m e w a y: p e r c e p t i o n s o f w h o t h e c l i-

en t i s, ways in wh ic h the c l i en t i s spec ia l , an d ways in

w h i c h t h e c l i e n t i m p a c t s t h e t h er a p i s t, T h r o u g h o u t t h e r -

a py , e m p h a s i s i s p l a c e d o n t h e c l i e n t b e i n g a b l e t o e x -

p r e s s w h a t i s d i f f i c u l t f o r h i m o r h e r t o e x p r e s s t o t h e

t h e r a p is t . Q u e s t i o n n a i r e s g i v e n to t h e c l i e n t a t t h e b e g i n -

n i n g , m i d d l e , a n d e n d o f t h e r a p y ( s ee T a b le 2 f o r s a m p l e

q u e s t i o n s ) e n c o u r a g e t h e c l i e n t t o sa y w h a t i s g e n e r a l l y

d i f f i c u l t t o sa y, w h e t h e r t h e y b e c r i t i c i s m s , f e a r s , l o n g i n g s ,

o r a p p r e c i a t i o n . F E C T t h e r a p i st s m o d e l i n t i m a c y sk il ls

f o r c l i e n t s b y e x p r e s s i n g c a r i n g , e x p r e s s i n g f e e l i n g s , t e l l-

i n g c l i e n t s w h a t t h e y s e e as t h e i r s t r e n g t h s , t a l k i n g a b o u t

c o n c e r n s i n a w a y t h a t v al i d a te s t h e m , a n d m a k i n g r e q u e s t s

4 . N o t i c e C R B s :

B o t h P r o b l e m s a n d h n p r o v e m e n t s

B a s e d o n t h e c a s e c o n c e p t u a l i z a t i o n , F E C T t h e r a p is t s

h y p o t h e s i z e a b o u t a n d l o o k f o r s p e ci f ic C R B s . A f e w o f

t h e m o s t c o m m o n d o m a i n s f o ll o w.

Cognitive CRBs. I m p o r t a n t c o g n i t i v e C R B s c a n h e

i d e n t i f i e d b y e x a m i n i n g t h e c l i e n t 's c o r e b e l i ef s , w h i c h

a r e i d e n t i f i e d i n t h e c o u r s e o f s t a n d a r d C T . C o r e b e l i e f s

c a n b e t r a n s l a t e d i n t o c o g n i t i v e CRBs , a n d t h i s w i l l f a c il i -

t a t e t h e t h e r a p i s t ' s a w a r e n e s s o f t h e i r p o t e n t i a l . Ta b l e 1

Table I

Potentia l Core Bel iefs and Correspo nding Antic ipated CRBs

Core Issue Anticipated CRB

Alone

Defective

Different

Doe s n ' t n l e a s u re up

Failure

Helpless

Inadequate

Incompetent

Ineffective

Infer ior

I,oser

Loser (in relationships)

Feels this way, even w ith therap ist.

As seen by therapist.

As seen by therapist or in reactions to

therapy.

As seen by therapist.

In therapy. With therapy tasks,

homework.

In relation to therapist, can't influence

therapist.

To understand the therapy, to get better

with this treatment.

In therapy.

In therapy.

To therapist, to othe r clients.

In relation to therapist, as seen by

therapist, to be in therapy.

In therapy relationship.

Ta b l e 2

Samp le Beginning, Middle , and End of Therapy

Quest ionnaire I tems*

Beginning of Therapy

I notice these similarities and differences between my usual style

of beginning and how I am beginning this re la t ion ship . . .

I will increase the likelihoo d of having a good exp erience and

get t ing what I want f rom therapy i f . . .

Middle of Therapy

I 'm having a hard t ime expressing myself ab ou t . . .

I want you to kn ow .. .

I t would be diff icul t for me to fac e . . .

I am interes ted in changing my therapy to incl ud e.. .

I could improve our re la t ionship by. . .

Yon could improve our re la t ionship by .. .

I have a hard t ime express ing myself ab ou t . . .

I t is hard for me to te l l you abo ut . . .

What bothers me about you is . . .

End o f Therapy

For many clients, the end of therapy brings up feelings and

mem ories of previous transitions and losses. What thoughts

and feelings do endings in general bring up for you?

What thoughts and feelings are you having about the ending of

this therapy relationship?

What have you learned, what has been helpful for you in this

therapy?

What stands out to you most about yonr interactions with your

therapist?

What do you like and appreciate about your therapist?

What regrets do you have about the therapy o r what would you

like to have gone differently?

* Adapted ti-om Bmcknm=Gordon, Gangi, and Wallman (1988).




7/18



Enhancing Cognitive Therapy 219

(I want, I need , I would like). FECT therapists also mod el

self-disclosure whe n it is in the client' s best int eres t (i.e.,

when relevant to the client 's issues, offering support, un-

derstanding, encouragement , hope, and the sense that

the clie nt is not alone).

Avoidance CRBs From a behavioral viewpoint, avoid-

ance is one of the major factors in the etiology and main-

tenan ce of depression (Ferster, 1973), and avoidance

CRBs are often a target in FECT. For many clients, thera-

peutic change is facilitated when avoidance is gently

blocked and clients are encouraged to take risks outside

of their usual comfort zone both in the session and in

daily life. For example, a client re mains silent for a mo-

men t and looks t roubled in response to a question. When

the therapist inquires further, the client says, Oh, I don' t

know, noth ing important . This may be a CRB1. That is,

in daily life, the client may avoid talking and feeling

abou t t roubl ing topics by using such dismissive phrases.

This type of CRB1 prec lude s the possibility of the client's

resolving the issue that she or he is avoiding, and inter-

feres with fo rming more satisfying relationships. Gentle

inquiry into nothi ng importa nt may pro mpt CRB2s,

which, in this case, may be th e c lient identi fying and ex-

pressing his or he r feeling of discomfort to the therapist.

The therapist should take care that his or her response to

the CRB2 will natu rally reinfor ce the new behavior. This

may involve risk-taking and real emotional involvement

on the part of the therapist, so the therapist should also

be aware of his or her own avoidance CRBs.

5 . A s k Q u e s t i o n s t o E v o k e C R B s

FECT therapists ask questions that bring the client 's

at tent ion to their thoughts and feel ings at the moment

about the therapy or therapeutic relationship. Table 3

presents several useful questions of this type.

6 . I nc r e a s e The r a p i s t Se l f - Awa r e ne s s a s a n A i d t o

D e t e c t i n g a n d B e i n g A w a r e o f C R B s

FECT therapists use their personal reactions to alert

them to client CRBs. The more therapists are aware of

and understand their own reactions to their clients, the

easier it will be for them to detect CRBs and resp ond ap-

propriately. For example, during supervision co-author

Mavis Tsai noticed that in a tape of a session, when a cli-

ent expressed warmth and appreciation toward the ther-

apist, the therapist ch ange d the subject without acknowl-

edging what the client had said. Dr. Tsai also noticed that

this therapist tended to be unco mfort able when Dr. Tsai

comp lim ent ed him. Whe n this was poin ted out, the ther-

apist became more aware of this discomfort and foc used

on being more receptive and reinforcing when compli-

mente d. Subsequently, he was better able to detect an d

naturally reinforce positive inter perso nal behaviors of his

clients. Table 4 presents sample questions that can be

used during supervision of FECT therapists to increase

self-awareness relat ed to provi sion of FECT.

7 . U s e t h e M o d i f i e d T h o u g h t R e c o r d

We modified the thou ght recor d (A. T. Beck et al., 1979,

p. 403) use d du ri ng CT in the following ways. First, the in-

structions were modified to inc lude the expan ded ratio-

nale: The clie nt is asked to con side r whethe r the A-B-C, A-C,

or A-C-B paradig ms fit his or her particula r experiences.

Begin filling out this record with the pr oblemati c

situati on, what you did, or wha t you felt. If possible,

denote whether the thinking, feel ing, or doing

came first, second, or t hird (which did you experi-

ence first, second, an d third?).

Second, a new colum n, In Vivo, has bee n added to

the for m to facilitate the th erapi st-cl ient focus. After

Table 3

Useful Sample Questions to Evoke

CRB

What's your reaction to . . . what I just said?

to the rationale I jus t gave?

to me as your therapist?

to agenda setting?

to structured therapy?

to the homework assignment?

to time-limited 20-session herapy?

What were you thinking/ feel ingon your way to therapy today?

What are your behaviors that tend to bring closeness in your

relationships?

What do you tend to do that decreases closeness in your

relationships?

How would you feet about us watching for your behaviors in here

which increase or decrease closeness?

What were yon thinking/feelingwhile you were waiting for me out

in the waiting room?

Table 4

Sample Ques tions for Use During Supervision of FECTTherapists

to Increase Self-Awareness

What thoughts and feelings is the cl ient stirring up in you?

How can these reactions help/h ind er the client or the therapy?

What does this tell you about the client?

What does this tell you about yourself?.

What are your own CRBls and CRB2s in relationships and

particularly as they pertain to your work with this client?

What would be helpful to the c lient and also promote better

therapist behavior? What do you uniquelybring to the therapy

relationship?

How do you think the ways you've been hurt emotionally shaped

who you are (your behavior) as a therapist, both positivelyand

negatively?

In general, what do you think your strengths and weaknesses are as

a therapist?

What concerns and apprehensions do you have as you begin seeing

FECT clients?




8/18



220 Kohlenberg et al.

d e n o t i n g t h e t h o u g h t s , f e e l i n g s , a n d a c t i o n s t h a t o c -

c u r r e d i n r e s p o n s e t o t h e p a r t i c u l a r e v e n t i n d a i l y l if e , t h e

c l i e n t is a sk e d , " H o w m i g h t s i m i l ar p r o b l e m a t i c t h o u g h t s ,

f e e li n g s, a n d / o r a c t i o n s c o m e u p i n s e s si o n , a b o u t the

t h e ra p y , o r b e t w e e n y o u a n d y o u r t h e r a p i s t? "

Th i r d , a n e w c o l u m n , " A l t e r n a t iv e , M o r e P r o d u c t i v e

W a y s o f Ac t i n g " a s k s c l ie n t s t o c o m e u p wi t h a l t e r n a t i v e

wa y s o f a c t i n g t h a t wo u l d h e l p t h e m a c h i e v e t h e i r g o a l s.

Th e c l i e n t is a l s o a s k e d t o r a t e h i s o r h e r " Co m m i t m e n t t o

Ac t M o r e Ef f e ct i v el y " u s i n g t h e f o l l o wi n g s c a l e:

0 % No n e ( I c a n ' t a c t b e t t e r wh i l e I h a v e n e g a -

t iv e t h o u g h t s a n d / o r f e e l in g s ) .

50% I am wi l l ing to g ive i t a t ry .

1 0 0 % Ve r y m u c h . I wi ll a c t e f fe c t i v e ly a n d h a v e m y

n e g a t i v e t h o u g h t s a n d f e e l i n g s a t t h e s a m e

t i m e .

Ba s e d o n a c c e p t a n c e ( Ha y e s , S t r o s a h l , & W i l s o n , 1 9 99 ;

L i n e h a n , 1 9 9 3) a n d b e h a v i o r a l a c t i v a t i o n ( J a c o b s o n e t a l. ,

1 9 96 ; M a r t e l l , Ad d i s , & J a c o b s o n , 2 0 0 1 ) a p p r o a c h e s , t h i s

c o l u m n c a n b e u s e d t o r a i s e t h e i s s u e t h a t i t i s p o s s i b l e

t o i m p r o v e e v e n i f o n e h a s n e g a t i v e t h o u g h t s a n d f e e l-

i n g s . Th i s a p p r o a c h i s p a r t i c u l a r l y u s e fi f l f o r h e l p i n g c l i -

e n t s w h o d o n o t i m p r o v e w i t h s t a n d a r d c o g n i t i v e t h e >

a p y i n t e r v e n t i o n s o r f o r t h o s e w h o r e j e c t t h e c o g n i t i v e

h y p o t h e s i s .

T h e s e s e v en s p e c if i c t e c h n i q u e s i n c o r p o r a t i n g t wo

m a i n e n h a n c e m e n t s t o C T w e r e t e s t ed i n t h e c o u r s e o f a

3-year s tudy.

E m p i r i c a l F i n d i n g s

De p r e s s e d s u b j e c t s we r e s e q u e n t i a l l y a s s i g n e d , i n

wa v es , t o e a c h o f f o u r e x p e r i e n c e d c o g n i t i v e t h e r a p i s t s .

Du r i n g t h e f i rs t 6 m o n t h s o f t h e s t u d y, 1 8 s u b je c t s we r e a s-

s i g n e d t o C T a n d r e c e i v e d s t a n d a r d C T t o r d e p r e s s i o n . I n

t h e 7 t h m o n t h , F E C T b e g a n a n d t h e n e x t 2 8 s u b j e c t s

w e r e s e q u e n t i a l l y a s s i g n e d i n w av e s to t h e s a m e f o u r

t h e r a p i s t s .

M e t h o d

Clients

El i g i b i li t y c r i t e r i a we r e a d i a g n o s i s o f m a j o r d e p r e s s i v e

d i s o r d e r a c c o r d i n g t o t h e S t r u c t u r e d C l i n i c a l I n t e r v i e w

f o r

DSM-IV

(SCID; Fi r s t , Spi t zer , Gibbon, & Wi l l i ams ,

1 9 9 5 ) a n d a s c o r e o f 1 8 o r g r e a t e r o n t h e Be c k De p r e s -

s i o n I n v e n t o r y ( BDI ; Be c k , W a r d , M e n d e l s o n , M o c k , &

E r b a u g h , 1 9 6 1 ) . E x c l u s i o n c r i t e r i a w e r e t h e s a m e a s

J a c o b s o n e t a l. ( 1 9 9 6 ) .

P a r t i c i p a n ts w e re r e c r u i t e d t h r o u g h c o m m u n i t y c l i n ic

r e f e r r a l s a n d n e w s p a p e r a d v e r t i s e m e n t s . Af t e r a n i n i t i a l

p h o n e s c r e e n i n g , p a r t i c i p a n t s we r e g i v e n a f u l l d i a g n o s t i c

e v a l u a t i o n t o d e t e r m i n e s t u d y el i g ib i li t y . Of t h e 1 1 6

par-

t i c i p a n t s i n t e r v i e we d , 4 9 m e t f u l l e l i g i b il i t y c r i t e r i a

a nd

w e r e a c c e p t e d into the s tu d y. T h r e e p a r t i c i p a n t s d r o p p e d

b e f o r e t h e r a p i s t a s s i g n m e n t ; 4 6 p a r t i c i p a n t s we r e a s-

s i g n e d t o e i t h e r CT ( 1 8 c l i e n t s ) o r FECT ( 2 8 cl i e n t s ) a nd

s t a r t e d t h e r a p y . Two a d d i t i o n a l c l i e n t s ( o n e CT a n d o n e

F E C T ) w e r e r e m o v e d f r o m t h e s t u d y a f t e r t h e r a p y b e g a n .

O n e w a s d u e t o a t h e r a p i s t m e d i c a l e m e r g e n c y a n d o n e

w a s d u e t o t h e e m e r g e n c e o f a se v e re p e r s o n a l i t y d i s o r d e r

m i s s e d d u r i n g s c r e e n i n g . P a r t i c i p a n t s ' m e a n a g e w a s

4 1 . 6 9 + 9 . 6 1 ; 6 4 % we r e f e m a l e , 3 8 .5 % we r e m a r r i e d o r

l iv i n g w i t h s o m e o n e , a n d 4 6 % h a d g r a d u a t e d f r o m a

4 - y e a r c o l l e g e .

Therapists

O u r r e s e a r c h t h e r a p i s t s h a d b e e n i n p r a c t i c e f o r a t

l e a s t 1 0 y e a r s a n d h a d s e r v e d a s c o g n i t i v e t h e r a p y r e -

s e a r c h t h e r a p i s t s o n p r i o r c l i n i c a l t r ia l s . Th r e e t h e r a p i s t s

we r e p s y c h o l o g i s t s ; o n e wa s a s o c i a l wo r k e r . Two t h e r a -

p i s ts we r e b o a r d c e r t i f i e d b y th e Ac a d e m y o f Co g n i t i v e

Th e r a p y .

Pro cedure

Standard CTphase. Ea c h t h e r a p i s t wa s i n s t r u c t e d t o d o

2 0 - s e s s i o n CT f o r d e p r e s s i o n , u s i n g A. T . Be c k a n d c o l -

l e a g u e s ( 1 9 79 ) a n d J. S . Be c k ( 1 9 9 5) a s m a n u a l s . Th e

t h e r a p i s t s m e t f o r we e k l y g r o u p s u p e r v i s i o n m e e t i n g s . DI .

S a n d r a C o f f m a n , a n e x p e r i e n c e d c o g n i t iv e t h e r a p i s t w h o

s e r v e d a s a r e s e a r c h t h e r a p i s t o n t wo p r i o r c l i n i c a l t r ia l s ,

a t t e n d e d a b o u t 5 0 % o f t h e g r o u p m e e t i n g s d u r i n g t h e

C T p h a s e a n d p r o v i d e d i n d i v i d u a l C T s u p e r v is i o n . A d d i -

t i on a l ly ; Dr. Ke i t h Do b s o n r a t e d f ou l" se s s i o n s f r o m e a c h

t h e r a p y c a s e f o r c o m p e t e n c y o n t h e C o g n i t i v e T h e r a p y

Scale (Do bson , Shaw, & Vall i s, 1985; Vall i s, Shaw, & Dob -

s o n , 1 98 6) a n d o n g o i n g f e e d b a c k b a s e d o n t h e s e r a ti n g s

wa s p ro x d d e d t o t h e t h e r a p i s t s .

PECT phase.

T h e s a m e f o u r t h e r a p i s t s b e g a n F E C T

t r e a t m e n t d u r i n g t h e s e c o n d y e a r o f t h e s tu d y. T r a i n in g

i n F E C T c o n s i s t e d o f a 6 - h o u r w o r k s h o p a n d w e e k l y

g r o u p a n d i n d i v i d u a l su p e r v i s io n f r o m D r . K o h l e n b e r g o r

Dr . Ts a i . Th e t r e a t m e n t m a n u a l s f o r t h i s p h a s e c o n s i s t e d

of the two CT boo ks (A. T. Beck e t a l . , 1979; J . S . Beck,

1 9 9 5 ), t h e FAP b o o k ( R . J . Ko h l e n b e r g & Ts ai , 1 9 91 ) , and

s u p p l e m e n t a l F E C T m a t e r i a l s , s u c h a s t h e q u e s t i o n s i n

T a b le s 1 t h r o u g h 4 a n d f o r m s c o m m o n l y u s e d i n C T t h a t

we r e m o d i f i e d t o b e c o n s i s t e n t wi th FECT.

Measures

W e wa n t e d t o m e a s u r e s e v e r al d i f f e r e n t c l a s se s o f v a r i-

a b l e s i n t h i s st u dy . F i rs t , we wa n t e d o u r s t u d y t o b e c o m p a -

r a b l e t o t r a d i t i o n a l o u t c o m e s t u d i e s o n t r e a t m e n t f o r

d e p r e s s i o n , s o t r a d it i o n a l o u t c o m e m e a s u r e s w e r e u s e d

(e .g . , Elk in e t a l . , 1989) . We used (a ) the 17- i t em Hami l -

t o n Ra t i n g Sc a l e f o r De p r e s s i o n ( HRSD; Ha m i l t o n , 1 9 6 7) ;

( b ) t h e Gl o b a l As s e s s m e n t o f Fu n c t i o n i n g Sc a l e ~GAF;




9/18



2 2 2 K o h l e n b e r g e t a l .

Table 5

Mean Score s on Major Out com e Variables by Condition, p Values and Effect Sizes

CT FECT

Time

N M + SD N M +- SD

ures a s those wi th le s s than a 25% red uc t io n

in sym ptom s . F igure 3 shows the pe r cen ta ge

of fa ilu re s in CT a nd F ECT for each ou t -

com e m easure . F ECT had fewer fa i lure s than

p ES

did CT on a l l measures .

R e m i s s i o n .

Def in ing rem is s ion a t the end

.20 .28 of tr ea tm en t as HRSD 6 or less, FECT pa-

.30 .17 dent s show ed an inc rem ent al increase in re-

miss ion of 67%. Eig htee n of 23 (78.3%)

.O6 .53 FECT pat ient s rem it t ed com par ed to 46.7%

.40 .08 (8 /1 5) of CT cli ent s (X2 = 4 .03, p = .049 ).

Di f fe rences in rem is s ion ra te s de f ined a s

.06 .61 BDI 8 or less wer e no t statistically signi fican t

.10 .48 be tw een cond iti ons . It is no t clear as to why

re l i ab le d i f fe rences in rem is s ion were foun d

.29 .19 only with the HRSD crite rion .

.03 .65

R e l a p s e a n a l y s e s .

Since we only had a 3-

m ont h fo l low-up a s ses sm ent , our ana lyses o f

re lapse were based on th i s l im i ta t ion . We

looked a t

s u s t a i n e d r e m i s s i o n

rates (SR; Hol-

Ion, 2001) a t the 3 -mon th fol low-up. A c l ient

was in S R i f he / sh e was rando m ized to t reat -

m ent , d id no t d rop ou t a t any po in t in the

s tudy, was not c l inical ly dep res sed a t th e end

of acu te t rea tm ent (HRS D < 13), and re -

m a i n e d d e p r e s s i o n - f r e e t h r o u g h o u t t h e

fo l low-up pe r io d (d id no t m ee t c r i t e r i a fo r

depres s ion fo r 2 weeks accord ing to the L IF E

in te rv iew) . Th i s index i s an im provem ent

over s imple re lapse ra tes for two reasons . F irs t , i t incl udes

a ll c l i en t s rando m ized to t rea t m ent an d thus i s an in ten t -

to-treat analys is , which is more inclus ive and powerful .

BDI Pre 15 21.67 +- 8.09 23 21.65 +- 5.36

Pos t 15 10.67 +- 10.03 23 8.61 -+ 5.45

Follow-up 15 8.87 + 7.43 23 7.83 -+ 4.76

HRSD Pre 15 14.93 +- 4.06 23 14.65 -+ 3.75

Pos t 15 8.60 + 7.12 23 5.52 -+ 4.54

Follow-up 15 4.47 + 4.24 23 4.04 -+ 3.69

SCL-90 Pre 15 0.92 -+ 0.42 23 0.89 +- 0.35

Pos t 11 a 0.54 -+ 0.42 18b 0.35 -4- 0.20

Follow-up 13 c 0.66 + 0.37 17 a 0.46 + 0.43

GAF Pre 15 54.67 +- 5.23 23 55.09 -+ 7.82

Pos t 15 70.27 +- 15.52 23 73.13 +- 13.79

Follow-up 15 78.87 +- 11.42 23 85.39 +- 9.52

Note. p = p

value for between condition ANCOVA;

ES

= Effect size; BDI = Beck Depression

Inventory; HRSD = 17-item Hamilto n Rating Scale for Depression; SCL-90 = Symp tom

Check-List 90, total score; GAF = Global Assessment of Functio ning.

aFour CT clients did no t ret urn their posttreatment assessment packets (which included the

SCL-90 and SAD).

b Five FECT clients did not return their po st-treatment assessment packets (which includ ed

the SCL-90 and SAD).

c Two CT clients did not return their 3-month follow-up assessment packets (which inclu ded

the SCL-90 and SAD).

~Five FECT clients did no t ret urn their 3 -month follow-up assessment packets (which inclu ded

the SCL-90 and SAD), and o ne cl ient did no t ret urn the SCL-90 with the follow-up assessment

packet.

had m ore re spo nde r s than d id CT on a ll m easures . Aver -

aging the BDI and HRSD, 79% o f FECT cl ients and 60%

of CT c l i en ts re sponde d to t rea tm ent . We de f ine d fai l-

90

[ ] C T

8O

i

70

~ 6o

U 50

40

30 -- -

BDI HRSD SCL90-T GAF

Outcome measu re

Figure 2 . P e r c en t o f C T a n d F EC T r e s p o n d e r s o n m a j o r o u t c o m e

va r iab les . BDI = Beck Dep ress ion Inven to ry ; HRSD = 17 - i t em

H a m i l t o n R a t i n g S c a le fo r D e p r e s s i o n ; S C L - 90 T = S y m p t o m

Check-L is t , 90 I t em Vers ion , t o ta l sco re ; GAF = G loba l Assess -

men t o f Func t ion ing .

50

4O

= 30

Ii

z

8 2 0

L-

n

10

B D I H R S D S C L 9 0 - T G A F

O u t c o m e m e a s u r e

Figure

3. Perce nt of CT and FECT failures on majo r ou tc om e

variables. BDI = Beck Dep ress ion Inventory ; HRSD = 17-it em

Hamilton Rating Scale for Depr essio n; SCL-90T = S ymp to m

Check-List, 90 Item Version, total scor e; GAF = Global Assess -

ment of Functioning.




10/18



Enhanc ing Cognitive Therapy 221

Endicott, Spitzer, Fleiss, & Cohen, 1976); (c) the Beck De-

pression Inve ntor y (BDI; A. T. Beck et al., 1961); and (d)

the Symptom Checklist-90 Total Score (SCL-90; Deroga-

tis, Lipman, & Covey, 1973). These four measures are es-

tablished instruments for the me asu reme nt of depressive

symptoms (BDI and HRSD), overall symptoms (SCL-90

T), a nd general level of func tioni ng (GAF). All measures

were administered at pretreatment, posttreatment, and at

a 3-month fbllow-up. The HRSD and GAF were com-

pleted by a trained evaluator at pretr eatm ent an d follow-

up and by the therapist during the final session. Also, to

assess diagnostic status and relapse rates at the 3-month

fol low-up, we adminis tere d the Lon gitud inal Interval

Follow-up Evaluation (LIFE; Keller et al., 1987), a semi-

structured retrospective interwiew that assesses the longi-

tudinal course of depression and other disorders.

Second , we were inter este d specifically in the effects of

the FECT enhancement-s that emphasize inter person al

proble ms and improveme nts, so we include d several mea-

sures of interpersonal funct ioning. We administered the

Social Support Questionnaire (SSQ; Sarason, Levine,

Basham, & Sarason, 1983), a well-validated measure that

asks subjects to list up to ni ne i ndividua ls to whom sub-

jects feel they could turn for support in each of six differ-

ent situations and to rate their satisfaction with available

support for each situatio n on a 6-point Likert scale. The

mea n nu mb er of individuals and mea n satisfaction rat-

ings across the six situations are used as subscale scores.

We also administered the Social Avoidance and Distress

Scale (SAD; Watson & Friend, 1969). Although the SAD

is widely used in tr eatm ent re search on social phobia, we

believe it has relevance to depression in general and to

FECT treatment of depression in particular. This is be-

cause a behavioral view of depression specifically empha-

sizes a lack or avoidance of social reinforcers (Boiling,

Kohl enbe rg, & Parker, 2000; Lewins ohn, 1974), and over-

coming social avoidance is targeted in both FECT and

Behavioral Activation treatments for depression.

We also wanted a measur e of relationship satisfaction

that tracked progress weekly thr ough out therapy. Before

beg inn ing each therapy session, clients responded to two

questions (in a confidential, sealed quest ionna ire that

the therapist did not see) about the ir interpers onal relat-

ing during the previous week. The first question was,

Have your relationships bee n different than usual? Cli-

ents were asked to res pond to this question on a 5-point

scale (1 = much worse, 3 = no change, and 5 = mu ch better).

The second q uestion was, If your relationships are differ-

ent this week, is this diffe rence du e to therapy? Clients

were asked to res pon d on a 4-point scale (1 = due to other

factors, 4 = definitely due to therapy).

We also con duct ed several intensive videotape rating

projects to assess additiona l client reactions and changes

not assessed by existing measures. First, we were inter-

ested in evaluat ing the effect of the FECT enh anc eme nt

to the CT rationale. Second, we assessed additional rela-

t ionship improvements using information gleaned from

the diagnostic interviews before the study started a nd at

3-month follow-up. Third, we assessed statements made

by clients themselves during the final therapy session

using a new scale, created throu gh a con tent analysis pro-

cedure, to assess for patterns of improve ments from the

client s' perspectives. Finally, in orde r to me asur e thera-

pist adherence and competence, we created and adminis-

tered a mea sure to check that the therapists were able to

implement FECT and that FECT as implemented dif-

fered from standard CT. We assessed CT competency

using the Cognitive Therapy Scale (CTS; Dobson et al.,

1985; Vallis et al., 1986). Eac h o f these proj ects will be d e-

scribed mor e fully below.

R e s u l t s

Because this study was not a randomized clinical trial,

it is not possible to una mbigu ously attribute outco me dif-

ferences to the treatment conditions. Thus, our conclu-

sions about ou tcome are preli minary in nature. Despite

the numerous analyses conducted, we elected to retain

an un corr ect ed pva lue of .05 and risk Type I errors be-

cause of the pre l imina ry and exploratory nature of

this study.

Major Outcom es

Statistical significance.

We first tested for statistical sig-

nificance of mean differences between treatmen t condi-

tions on the four maj or outco me measur es using ANCOVA,

with pretrea tment scores on each measure en tered as co-

variates. Table 5 shows sample sizes, means and standard

deviations for CT and FECT on the four measures at pre-

treatment, posttreatment, and follow-up. Table 5 also

shows the p value (one -tai led) f or each ANCOVA com-

paring CT and FECT. Results favored FECT at all time

points, with a significant difference f ound on the GAF at

follow-up, and trends found on the HRSD and SCL-90 at

posttreatment.

Effect sizes. Because o f small sample size, we were par-

ticularly interested in effect sizes as measured by d, and

used adjusted values as instructed by Cohen (1988, p.

380). Across all measures (see Table 5), the mean post-

treatment effect size was .40, and the mean follow-up ef-

fect size was .34.

Clinical s ignif icance. We also split our clients into

groups of responders and failures. We defin ed re-

spond ers as those with a clinically signific ant red uct ion in

depressive symptoms, defined as greater t han or equal to

50% reduction in overall symptom severity measured at

pretreatment. Figure 2 shows the percentage of respond-

ers in CT and FECT for each outcome measure. FECT




11/18



Enhancing Cognitive Therapy 223

S e c o n d , i t t a k es i n t o a c c o u n t b o t h t h o s e w h o d i d n o t r e -

s p o n d t o a c u t e t r e a t m e n t a n d t h o s e w h o r e l a p s e d a f t e r a

r e s p o n s e ; t h u s i t m o r e f u ll y c a p t u r e s t h e r a n g e o f d e p re s -

s i o n t r e a t m e n t o u t c o m e s p o s s i bl e . W e f o u n d t h a t 4 7 . 1 %

o f C T c l i e n t s a n d 7 4 . 1 % o f F E C T c l i e n t s w e r e i n S R a t

f o l l o w - u p ( X2 = 1 .29 , p = .068 ) . Th i s ind ex sub sum es s im-

p l e r e l a p se r a t# s: O n e C T c l i e n t a n d o n e F E C T c l i e n t h a d

r e l a p s e d .

Interpersonal Functioning Outcomes

O n t h e S S O~ n o s i g n i f i c a n t d i f f e r e n c e s b e t w e e n c o n d i -

t i o n s w e r e f o u n d i n t h e n u m b e r o f s o c ia l s u p p o r t s c l i e n t s

i d e n t i f i e d , a l t h o u g h r e s ul t s f a v o r e d F E C T w i t h s m a l l ef -

f e c t s i ze s a t p o s t t r e a t m e n t ( . 2 9) a n d f o l l o w - u p ( . 2 7 ) .

H o w e v e r , s i g n i f i c a n t d i f f e r e n c e s w e r e f o u n d i n r e l a t io n -

s h i p s a t i s f a c t i o n w i t h l a r g e e f f e c t s i z e s a t p o s t t r e a t m e n t ,

F ( 1 , 2 6 ) - 5 . 5 7 , p = 0 . 0 3 , E S = . 9 1 , a n d f o l l o w - u p ,

F(1, 28) = 7 .45, p = 0 .01, E S = .99 ( see Tab le 6 ) . CT c l i -

e n t s o n a v e r a g e d i d n o t i m p r o v e o n r e l a t i o n s h i p s a t i s f a c -

t i o n a t p o s t t r e a t m e n t ( p e r c e n t c h a n g e = 0 . 0 0 --- 0 . 3 8 ) o r

f o l l o w - u p ( - 0 . 0 3 + 0 . 2 2 ), w h i l e F E C T c li e n t s i m p r o v e d

4 7 % a t p o s t t r e a t m e n t a n d 3 9 % b y f o l lo w - u p . D i f f e r e n c e s

i n p e r c e n t c h a n g e s c o r e s b e t w e e n c o n d i t i o n s w e r e s i g ni f -

i c a n t ( p o s t t r e a t m e n t : t [ 27 ] = 1 . 69 , p = . 05 0 ; f o l l o w - u p

t[29] = 1 .84, p = .0 38) .

O n t h e S A D , n o s i g n i f ic a n t d i ff e r e n c e s w e r e f o u n d i n

s o c ia l a v o i d a n c e b e t w e e n g r o u p s u s i n g A N C O V A a t p o s t-

t r e a t m e n t o r a t f o l l o w - up , b u t m o d e r a t e e f f e c t s iz e s w e r e

f o u n d a t b o t h t i m e p o i n ts f a v o r i ng F E C T ( p o s t t r e a t m e n t

d = . 3 8; f o l l o w - u p d = . 3 6 ) . Pe r c e n t c h a n g e s c o r e s i n d i -

c a t e d a w o r s e n i n g o f s o c ia l a n x i e t y o v e r th e c o u r s e o f

t h e r a p y f o r C T , w h i l e t h e F E C T a v e r a g e i n d i c a t e d a n i m -

p r o v e m e n t ( CT = - 0 . 2 9 + 1 . 0 8 ; FE CT = 0 . 3 6 --- 0 . 4 3 ;

t [ 27 ] = 2 . 2 7 , p = . 0 1 6 ) . S i m i l a r d i f f e r e n c e s w e r e f o u n d a t

fo l low -up (C T = 0 .09 _+ 0 .63 ; FE CT = 0 .39 + 0 .43 ;

t [29] = 1 .59, p = .0 62) .

C o n c e r n i n g w e e k l y r e l a t i o n s h i p s a t is f a ct i o n, a s s h o w n

i n F i g u r e 4 ( a ) , b o t h C T a n d F E C T c l i e n ts c o n s i st e n t l y r e-

p o r t e d t h a t t h e i r r e l a t i o n s h i p s w e r e i m p r o v i n g a s t h e r a p y

p r o g r e s s e d . A s s h o w n i n F i g u r e 4 ( b ), b o t h g r o u p s a t t r i b -

u t e d t h is i m p r o v e m e n t i n c r e a s i n g ly t o t h er a p y, w i t h F E C T

Table 6

SSQ Relat ionship Sat isfact ion Subscale Score s by Condit ion,

p Values, and Effect Sizes

CT FECT

Time N M +- SD N M +- SD p ES

Pr e 15 4.02 -+ 1.48 23 4.04 +- 1.42 .97

Po st 11 4.08 - 1.61 18 4.69 -+ 0.92 .01 .91

Follo w-u p 13 4.05 -+ 1.66 18 4.76 _+ 1.24 .01 .99

Note. p = p value for between-conditions ANCOVA, ES = Effect size.

3

e-

A

CT

- - FE CT "~

,,. . . I ~ ./ .~ i '~

/ "---,,, J /~ " \ / J

v

~ k i i i L i i 4 r i i i i q i i J i i i i i i ~ i i i i I i J i I q k i I q

1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0

Session

4

0 3 3

t - -

.m

t-

o3

o)

B

~ CT t \ x

t

--F ECT /,,. / / \v / \ \ /

j \// ~ v

f i J i i p i q i ~ ; n q

1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0

Session

Figure 4 . Mean se l f - r epo r t ed r e l a t ionsh ip improvemen t s and

at t r ibutions for chang e o ver the course of therapy. (A) Mean ra t-

ings on ques t ion : H ave your r e l a t ionsh ips bee n d i f f e ren t than

usual? 1 = m u c h w o r s e , 3 = n o c h a n g e , and 5 = m u c h b e t t e r .

(B) Mean ra t ings on quest ion: I f your re la t ionships are different

th i s week , i s t h i s d i f f e rence due to the rapy? 1 = due t o

o t h r

factors , and 4 = d e f i n i t e l y due to t h er a p y .

s h o w i n g m o r e i m p r o v e m e n t t h a n C T a t al l b u t t h r e e t i m e

p o i n t s .

I n t e r p e rs o n a l f u n c t i o n i n g a n d t r e a tm e n t f a i l u re s . W e a l s o

l o o k e d s p e c if i c al l y a t h o w t h e t r e a t m e n t f a i l u re s ( t h o s e

w i t h l e ss t h a n 2 5 % c h a n g e o n t h e B D I ) d i d o n t h e s e m e a -

s u re s . S i n c e F E C T f o c u s e

04 enhancing ct for depression.pdf

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