A re-examination of process-outcome relations in cognitive therapy for depression: Disaggregating within-patient and between-patient effects.

OBJECTIVE: We previously examined alliance and therapist adherence as predictors of symptom change. Applying a new analytic strategy, we can ensure that any relations identified were not attributable to stable patient characteristics. METHOD: Participants were 57 depressed cognitive therapy patients. We disaggregated within- and between-patient variation in process measures. RESULTS: Between-patients, variability in adherence to Cognitive Methods and Negotiating/Structuring predicted patients' symptom change. Within-patients, only variability in ratings of adherence to Cognitive Methods predicted next-session symptom change. CONCLUSIONS: Relations involving between-patient process variables are potentially attributable to stable patient characteristics. However, the relation of within-patient Cognitive Methods and session-to-session symptom change cannot be attributed to stable characteristics and is consistent with a causal relationship.

Using Socratic Questioning to promote cognitive change and achieve depressive symptom reduction: Evidence of cognitive change as a mediator.

Socratic questioning has long been thought to play a critical role in cognitive behavioral therapy (CBT) for depression. Though use of Socratic questioning is theorized to achieve symptom reduction by promoting cognitive change, research has yet to investigate this pathway. In a sample of 123 clients participating in CBT for depression, we tested cognitive change as a mediator of the relation between Socratic questioning and symptom change in early treatment sessions. We found evidence of a significant indirect effect, consistent with cognitive change mediating the effect of Socratic questioning on change in depressive symptoms. Further analyses showed that pre-treatment CBT skills moderated the effect of Socratic questioning on cognitive change, with this relationship being stronger for clients who started treatment with lower CBT skills. These findings provide support for the view that Socratic questioning contributes to therapeutic gains in CBT through cognitive change. This study also provides initial evidence to suggest the use of Socratic questioning is particularly important for clients who begin treatment with particularly low CBT skills.

Therapist use of Socratic questioning predicts session-to-session symptom change in cognitive therapy for depression.

Socratic questioning is a key therapeutic strategy in cognitive therapy (CT) for depression. However, little is known regarding its relation to outcome. In this study, we examine therapist use of Socratic questioning as a predictor of session-to-session symptom change. Participants were 55 depressed adults who participated in a 16-week course of CT (see Adler, Strunk, & Fazio, 2015). Socratic questioning was assessed through observer ratings of the first three sessions. Socratic ratings were disaggregated into scores reflecting within-patient and between-patient variability to facilitate an examination of the relation of within-patient Socratic questioning and session-to-session symptom change. Because we examined within-patient variability in Socratic questioning, the identification of such a relation cannot be attributed to any stable patient characteristics that might otherwise introduce a spurious relation. Within-patient Socratic questioning significantly predicted session-to-session symptom change across the early sessions, with a one standard deviation increase in Socratic-Within predicting a 1.51-point decrease in BDI-II scores in the following session. Within-patient Socratic questioning continued to predict symptom change after controlling for within-patient ratings of the therapeutic alliance (i.e., Relationship and Agreement), suggesting that the relation of Socratic questioning and symptom change was not only independent of stable characteristics, but also within-patient variation in the alliance. Our results provide the first empirical support for a relation of therapist use of Socratic questioning and symptom change in CT for depression.

Identifying moderators of the adherence-outcome relation in cognitive therapy for depression.

OBJECTIVE: Little is known about the influence of patients' pretreatment characteristics on the adherence-outcome relation in cognitive therapy (CT) for depression. In a sample of 57 depressed adults participating in CT, the authors examined interactions between pretreatment patient characteristics and therapist adherence in predicting session-to-session symptom change. METHOD: Using items from the Collaborative Study Psychotherapy Rating Scale, the authors assessed 3 facets of therapist adherence: cognitive methods, negotiating/structuring, and behavioral methods/homework. Two graduate students rated Sessions 1-4 for adherence. Symptoms were assessed prior to each session with the Beck Depression Inventory-II. Moderators were assessed as part of patients' intake evaluations. RESULTS: After correcting for multiple comparisons, patient gender remained a significant moderator of the relationship between cognitive methods and next-session symptom change; cognitive methods more strongly predicted greater symptom improvement for women as compared to men. Pretreatment anxiety and number of prior depressive episodes were significant moderators of the relationship between behavioral methods/homework and next-session symptom change, with greater behavioral methods/homework predicting symptom improvement more strongly among patients high in pretreatment anxiety and among patients with relatively few prior depressive episodes. CONCLUSIONS: This is the first study to provide evidence of how therapist adherence is differentially related to outcome among depressed patients with different characteristics. If replicated, these findings may inform clinical decisions regarding the use of specific facets of adherence in CT for depression with specific patients.

Assessing Patients' Cognitive Therapy Skills: Initial Evaluation of the Competencies of Cognitive Therapy Scale.

In Cognitive Therapy (CT), therapists work to help patients develop skills to cope with negative affect. Most current methods of assessing patients' skills are cumbersome and impractical for clinical use. To address this issue, we developed and conducted an initial psychometric evaluation of self and therapist reported versions of a new measure of CT skills: the Competencies of Cognitive Therapy Scale (CCTS). We evaluated the CCTS at intake and post-treatment in a sample of 67 patients participating in CT. The CCTS correlated with a preexisting measure of CT skills (the Ways of Responding Questionnaire) and was also related to concurrent depressive symptoms. Across CT, self-reported improvements in CT competencies were associated with greater changes in depressive symptoms. These findings offer initial evidence for the validity of the CCTS. We discuss the CCTS in comparison with other measures of CT skills and suggest future research directions.