The Use and Nature of Present-Focused Interventions in Cognitive and Behavioral Therapies for Depression

THE USE AND NATURE OF PRESENT-FOCUSED INTERVENTIONS IN COGNITIVE AND BEHAVIORAL THERAPIES FOR DEPRESSION

JONATHAN W. KANTER AND SARA J. LANDES LAURA C. RUSCH University of Washington Medical School University of Wisconsin—Milwaukee GARETH I. HOLMAN AND SONJA K. SEDIVY URSULA WHITESIDE University of Wisconsin—Milwaukee University of Washington To improve cognitive and behavioral newer approaches. Therapists more often therapies (CBT) for depression, several performed therapy process and emotion approaches recommend an increased focused interventions, but these also focus on the occurrence of problems as tended to lack elaboration. they occur in the therapeutic relationship or in relation to the live therapy process, Keywords: cognitive behavioral ther- referred to as present-focused. A linger- apy, psychotherapeutic techniques, ma- ing question has been the degree to jor depression, therapeutic alliance which CBT therapists already engage in present-focused work. This study utilized Both cognitive therapy (CT; Beck, Rush, sessions from recent trials of CBT for Shaw, & Emery, 1979) and behavioral activation depression and, in Phase I, raters identi- (BA; Martell, Addis, & Jacobson, 2001) for de- fied present-focused interventions on a pression are considered to be empirically sup- turn-by-turn basis. Phase II raters used a ported (DeRubeis & Crits-Christoph, 1998; Dob- qualitative analysis to determine catego- son, 1989; Ekers, Richards, & Gilbody, 2008). ries of present-focused interventions. Re- However, both approaches leave ample room for improvement, in terms of acute response, remis- sults indicated that therapists rarely fo- sion, and prevention of relapse and recurrence cused on the therapeutic relationship; (e.g., Gortner, Gollan, Dobson, & Jacobson, when they did, it was often transient and 1998; Jacobson et al., 1996). For example, in a lacking in the elaborations suggested by recent meta-analysis of 12 trials comparing behavior therapy and cognitive therapy, it was found that at the end of treatment only 55% of Jonathan W. Kanter, Department of Psychology, University clients were classified as recovered (Ekers et al., of Wisconsin—Milwaukee; Laura C. Rusch, Department of 2008). In response to such data, multiple efforts Psychology, University of Wisconsin—Milwaukee; Sara J. to modify, present alternatives to, and otherwise Landes, Department of Psychiatry and Behavioral Sciences, improve cognitive and behavioral therapies University of Washington Medical School; Gareth I. Holman, 1 Department of Psychology, University of Washington; Ursula (CBT) are occurring. Whiteside, Department of Psychiatry and Behavioral Sci- ences, University of Washington Medical School; Sonya K. Sedivy, Department of Educational Psychology, University of 1 In this article, the term CBT refers collectively and loosely to Wisconsin—Milwaukee. the different cognitive and behavioral treatments discussed, as Correspondence regarding this article should be addressed well as to the broader set of similar treatment approaches. The to Jonathan W. Kanter, PhD, University of Wisconsin— term CT refers to a subset of CBT treatments, specifically Beck Milwaukee, Department of Psychology, PO Box 413, Mil- et al. (1979), J. Beck (1995) and other approaches that specifi- waukee, WI 53201. E-mail: [email protected] cally use the term cognitive therapy in their title.

220 Present-Focused Interventions in CBT for Depression

One avenue for improvement has been an in- 1990), Schema Focused Therapy (SFT; Young, creased focus on the occurrence of problems as 1999), Short-Term Cognitive Therapy (STCT; they occur in the here-and-now therapy moment Newman, 1998), and Integrated CT (ICT; Cas- (e.g., in relation to the therapeutic relationship or tonguay et al., 2004). In addition, Functional An- therapy process), which we refer to as present alytic Psychotherapy (FAP; Kohlenberg & Tsai, focused. This is not to say the present moment is 1991; Tsai et al., 2008) has been suggested as a ignored in CBT. In CT for depression, for exam- framework with which to enhance the therapeutic ple, the therapeutic relationship has been seen as relationship, and therefore outcomes in CT (re- an important common factor, necessary for the sulting in FAP-Enhanced CT, or FECT; Kohlen- establishment of collaborative empiricism, but berg, Kanter, Bolling, Parker, & Tsai, 2002; not the core mechanism of change (Goldfried & Kohlenberg & Tsai, 1991) and BA (FAP- Davila, 2005; Waddington, 2002). Traditional CT Enhanced BA, or FEBA; Kanter, Manos, Busch, manuals (Beck et al., 1979; J. Beck, 1995) note & Rusch, 2008). While these treatments vary the importance of establishing a strong collabo- from each other in terms of the theoretical models rative relationship, contain instructions for how that underlie the specific present-focused tech- to resolve difficulties and impasses in the rela- niques incorporated, they share a common em- tionship, and include several examples of phasis on work within the present moment as a relationship-focused interactions. The relation- proposed active mechanism of change. ship in BA is similar—the therapist is seen as a Much, but not all, of the emphasis in these coach or collaborator with the client, but the newer treatments is on the therapy relationship or relationship is not conceptualized as an active therapeutic alliance. For example, ICT (Caston- mechanism of change (Martell et al., 2001). In guay et al., 2004), using procedures first pre- other words, in both CT and BA, the relationship sented by Safran and colleagues (e.g., Safran & is an implicit rather than explicit priority. Segal, 1990; Safran & Muran, 2000), provides Likewise, CT and BAs focus on the therapy techniques for therapists to identify, explore, and process is clearly articulated, but not seen as address alliance ruptures as they arise in therapy, essential to the change process. At the beginning with the goal being a client’s direct exploration of and end of sessions, therapists are encouraged to their feelings toward the therapist, followed by discuss the therapy process and elicit feedback therapist empathic validation. CBASP (McCul- from the client about how he or she is reacting to lough, 2000), STCT (Newman, 1998), CT-PD the process. This feedback serves to identify (Beck et al., 1990), FECT (Kohlenberg et al., whether the client understands what the therapist 2002), and FEBA (Kanter et al., 2008), focusing is saying and to elicit potentially counterproduc- more broadly on the therapy relationship than just tive client responses to the treatment (e.g., Beck the alliance per se (Gelso & Samstag, 2008; Le- et al., 1979, pp. 100–101). In addition, CT ther- juez, Hopko, Levine, Gholkar, & Collins, 2005), apists are taught to see “hot cognitions” and cur- also emphasize identifying and resolving prob- rent emotions as opportunities for key cognitive lems that may occur between the client and ther- changes to occur. The primary focus in traditional apist as key facets of treatment. For example, CBT approaches, however, is on changing CBASP (McCullough, 2000) contains detailed thoughts and behavior related to the world out- instructions for dealing with a host of issues that side of therapy, not in relation to the here-and- may disrupt the therapeutic alliance, including now therapy moment, the therapy relationship, or therapist feelings of frustration and incompe- the therapy process. tence, client resistance to the therapeutic work, Several recent CBT variants shift these prior- lack of client improvement, hostile and angry ities and emphasize the present moment in spe- clients, and passive-dependent clients. Similarly, cific ways linked directly to core change pro- STCT (Newman, 1998) specifically highlights cesses. These treatments include J. Beck’s (2005) potential alliance ruptures due to clients feeling a approach to CT for challenging problems, Lea- loss of autonomy and control to the therapist, hy’s (2001) guidelines for overcoming resistance feeling rushed into tasks before they are ready, in CT, the Cognitive-Behavioral Analysis System and anticipating that abandonment will occur of Psychotherapy (CBASP; McCullough, 2000), when the therapy relationship ends, among other Cognitive Therapy for Personality Disorders issues. CT-PD (Beck et al., 1990) likewise fo- (CT-PD; Beck, Freeman, Davis, & Associates, cuses on problems with noncollaboration in the

221 Kanter therapeutic relationship, offering a number of Dynamic Psychotherapy (Crits-Christoph & Bar- strategies to target and explore possible causes of ber, 1991). Research on the use of present- noncollaboration, including, but not limited to, focused interactions in the CBT approaches re- lack of client skill, the role of culture, dysfunc- viewed herein is limited but encouraging, and tional beliefs, poor timing of interventions, prob- also largely consists of research on therapy rela- lems with goals of therapy, and client or therapist tionship processes. Of all of the treatments high- frustration with lack of progress. lighted above, CBASP is the most empirically Several approaches, including SFT (Young, supported. In a large trial, CBASP performed as 1999), CT-PD (Beck et al., 1990), STCT (New- well as nefazadone (Keller et al., 2000) and was man, 1998), and FECT (Kohlenberg et al., 2002) effective at preventing relapse (Klein et al., stress the importance of present-focused cogni- 2004). Furthermore, the best predictor of positive tive restructuring, wherein therapists pay partic- outcomes for CBASP was the overall degree of ular attention to clients’ immediate emotional emphasis therapists placed on discussing the ther- reactions to the therapist, therapy process, or apeutic relationship (Vocisano et al., 2004). In other aspects of the present moment and apply addition, FECT has been evaluated in one non- cognitive restructuring strategies, including the randomized trial (Kohlenberg et al., 2002) com- use of dysfunctional thought records, as these pared to CT. In this trial, both CT and FECT reactions occur. These strategies are largely con- performed equally; however, FECT clients dem- sistent with traditional CT techniques; the pri- onstrated large improvements on several mea- mary difference is that the beliefs targeted for sures of interpersonal functioning, as compared change are in-session present-focused beliefs with CT clients. Additional analyses of the FECT rather than beliefs about daily life events and study suggested that present-focused interven- relationships. tions, broadly defined, predicted client-reported Another common theme is strategic therapist progress during treatment (Kanter, Schildcrout, self-disclosure, advocated by SFT (Young, & Kohlenberg, 2005), and present-focused cog- 1999), STCT (Newman, 1998), FECT (Kohlen- nitive restructuring specifically predicted im- berg et al., 2002), FEBA (Kanter et al., 2008), proved outcomes at the end of treatment (Kohlen- and CBASP (McCullough, 2000). The rationale berg et al., 2002). ICT has been evaluated in two for disclosure varies; some employ it to challenge trials. The first (Castonguay et al., 2004) com- maladaptive and present-focused cognitions (e.g., pared ICT to a wait-list control, with encouraging SFT, STCT, and FECT), while others employ results, and the second (Constantino et al., 2008) therapist self-disclosure of reactions to client be- compared ICT to traditional CT. In this trial, ICT havior as punishment or reinforcement (e.g., performed well, evidencing improved depression CBASP, FECT, and FEBA). rates, fewer dropouts, better perceived alliances, Finally, several approaches, including CBASP and higher perceived therapist empathy, as com- (McCullough, 2000), FECT (Kohlenberg et al., pared with traditional CT. 2002), and FEBA (Kanter et al., 2008) highlight the importance of comparing and contrasting Occurrence of Present-Focused Techniques in present-focused interactions with daily life situa- Traditional CBT tions. This is seen as important both in generating hypotheses about potential transference reactions Taken together, these findings suggest that not or other present-focused situations requiring ther- only are these treatments promising in terms of apeutic attention, as well facilitating generaliza- empirical outcomes, but there is accumulating tion of gains made during present-focused inter- support for the importance of the specific present- actions to daily life. focused interventions employed in these treat- There is of course considerable empirical sup- ments. A lingering question has been the degree port for the importance of the therapy relation- to which traditional CBT therapists already en- ship across different forms of psychotherapy gage in present-focused work, and if they do, the (Lambert & Barley, 2001). Much of this research degree to which this work parallels what is rec- either focuses on the relationship as a common ommended by these newer approaches. For ex- factor or as a specific factor in the context of ample, the original CT manual (Beck et al., 1979) non-CBT treatments, such as Brief Relational notes the importance of addressing transference Therapy (Safran & Muran, 2000) and Short-term reactions and provides several examples of tech-

222 Present-Focused Interventions in CBT for Depression niques specifically focused on the therapy or the inition, trained raters identified interventions on therapeutic relationship. J. Beck (1995) also pre- a turn-by-turn basis in selected sessions. In sents guidelines for using similar techniques Phase II, the identified present-focused inter- when working with challenging clients. The ventions were submitted to a qualitative anal- claim that CBT therapists already engage in this ysis to determine categories of present-focused work also has been made more directly. Lazarus interventions. The identified interventions were (2003) argued, “. . . would any competent thera- then categorized to provide a more detailed pist misunderstand and not address, in session, understanding of the nature of present-focused hostile behavior from a somewhat belligerent work in these treatments. youth who has problems with authority? Would any well-schooled CBT practitioner find it far- Method fetched to point out to a client that she appears to react to her therapist in the same way the she Therapy Sessions views her abusive husband, and then use in- session cues to deal with the problem?” The therapy sessions from two clinical trials, Kanter and colleagues (2005) and several stud- DeRubeis et al. (2005) and Dimidjian et al. ies by Goldfried and colleagues (Castonguay, (2006), were coded for the current project (see Hayes, Goldfried, & DeRubeis, 1995; Goldfried, the original reports for more detailed descriptions Castonguay, Hayes, Drozd, & Shapiro, 1997; of conditions, inclusion criteria, client demo- Goldfried, Raue, & Castonguay, 1998), all using graphic characteristics, and therapeutic proce- turn-by-turn coding systems to identify present- dures). In brief, DeRubeis et al. randomly as- focused work during psychotherapy sessions, col- signed 240 participants to 16 weeks of CT, 16 lectively suggest that research CT therapists typ- weeks of medication, or 8 weeks of pill placebo. ically do not engage in it. However, Kanter et al. Dimidjian et al. randomly assigned 241 partici- (2005) also suggested that even small incremen- pants to 16 weeks of CT, 16 weeks of BA, 16 tal improvements in the amount of present- weeks of medication, or 8 weeks of pill placebo. focused work may predict progress, so it may be In both trials, CT was performed according to the case that, even though these therapists did not Beck et al. (1979), with the DeRubeis et al. trial often employ present-focused interventions, the also incorporating Beck et al. (1990). BA was occasional well-timed intervention was signifi- based on Martell et al. (2001) and focused on cant. In addition, previous research has not indi- activating clients to contact positive reinforce- cated the nature or type of present-focused in- ment and countering avoidance and passivity that terventions employed, such as the degree to blocks activation. In addition, both clinical trials which observed interventions are consistent required clients to be diagnosed with Major De- with procedures recommended by recent vari- pressive Disorder according to the DSM–IV ants in psychotherapy. Finally, as the recent (American Psychiatric Association, 2000) and to variants gain empirical support, leakage of exceed a cut-off score on the 17-item version of these techniques into traditional CBT may oc- the Hamilton Rating Scale for Depression cur; thus, it is important to assess the work of (HRSD; Hamilton, 1967; Williams, 1988; 20 or recent CT therapists. Assessing the degree to greater for DeRubeis et al., and 14 or greater for which this occurs in BA is also important, since Dimidjian et al.) indicating moderate to severe this has not yet been investigated. depression symptom severity. The present study examines the degree to which CT and BA therapists engage in present- Clients focused work, when they do, and what exactly they do. We selected sessions from the CT con- DeRubeis et al. CT. In DeRubeis et al. dition of DeRubeis et al. (2005) and sessions (2005), 60 clients were randomly assigned to from the CT and BA conditions of Dimidjian et receive CT, of which 51 completed treatment. al. (2006). To ensure that any and all present- Sessions from 19 of the treatment completers focused interventions in these sessions would be were randomly selected and coded for the current identified, we engaged in a two-phase procedure. study, equally distributed across the two sites (9 In Phase I, a very wide and inclusive definition of from one site, 10 from the other). Treatment present focus was developed. Based on this def- lasted 16 weeks, however the number of sessions

223 Kanter varied as treatment was held twice weekly during Therapists the first 4 weeks, once or twice weekly during the middle 8 weeks, and once weekly during the final The CT therapists in DeRubeis et al. (2005) 4 weeks. Three sessions were selected and coded were five licensed clinical psychologists and one for each client representing a session from the psychiatric nurse practitioner. The CT therapists early (Sessions 4–9), middle (Sessions 8–17), in Dimidjian et al. (2006) were two licensed and late (Sessions 12–25) phases of therapy. In clinical psychologists and one licensed clinical total, 55 sessions were coded (two sessions were social worker. CT therapists from both conditions not coded due to administrative error). The mean followed standard CT protocols (Beck et al., age of the sample used in the current study from 1990, 1979; J. Beck, 1995). The BA therapists in this condition was 42.4 (SD ϭ 9.5; range 25–56) Dimidjian et al. consisted of three licensed clin- years and 58.0% of the sample was female. Re- ical psychologists. BA therapists followed the garding ethnicity, 88.0% of the sample was BA protocol by Martell and colleagues (2001). White. Dimidjian et al. CT. In Dimidjian et al. Phase I Coding Procedure (2006), 45 clients were randomly assigned to receive CT of which 39 completed treatment. Coding of sessions. Raters used a revised Sessions from 38 of the treatment completers coding scheme designed for a previous similar were coded for the current study (one did not study (Kanter et al., 2005). In this scheme, each have tapes available to code). Treatment lasted 16 therapist turn of speech is categorized into one of weeks with a maximum of 24 sessions. Sessions two mutually exclusive categories: “present- were held twice weekly for the first 8 weeks and focused” (PF) and “other”. PF was defined as talk once weekly for the next 8 weeks. Three sessions aimed at working on client problems that oc- were selected for each client representing a ses- curred in therapy in relation to the therapy pro- sion from the early (Sessions 4–6), middle (Ses- cess, the therapy relationship, or anything else sions 7–12), and late (Sessions 11–19) phases of having to do with therapy. “Other” was simply therapy. Treatment length was not equal in length defined as everything other than PF. In order to for each client and as a result early, middle, and maximize identification of PF turns, raters were late phases of therapy were based on total number instructed to rate a turn as PF if they identified of sessions for each client. In total, 112 sessions both PF and Other material in a single turn. were coded (two sessions were not coded due to Categorizations for each turn were based both on administrative error). The mean age of the sample the content of speech, as well as the context. For used in the current study from this condition was example, a turn would be coded as PF if it did not 39.5 (SD ϭ 11.1; range 19–60) years and 73.7% specifically refer to PF material, but was part of a of the sample was female. Regarding ethnicity, larger discussion that was focused on PF mate- 86.9% of the sample was White. rial. These instructions ensured that all potential Dimidjian et al. BA. In Dimidjian et al. PF turns would be coded; at this stage the aim (2006), 43 clients were randomly assigned to was to minimize false negatives by allowing for receive BA of which 36 completed treatment. more false positives. The following are examples Sessions from 33 of the treatment completers of PF therapist turns: were coded for the current study (three were “How did you feel about today’s session?” unavailable for coding). Similar to the Dimidjian “Well . . . I think we need to stop. But I’m et al. CT condition, three sessions were selected really tickled with your progress, and I think for each client representing a session from the you’re doing a great job.” early (Sessions 4–6), middle (Sessions 9–12), “Remember last time as we would talk about and late (Sessions 13–18) phases of therapy. In things sometimes you would kind of, you’d al- total, 92 sessions were coded (seven sessions ready come up with how a solution might not were not coded due to administrative error). The work before we even would finish talking about mean age of the sample used in the current study it, and I was pointing out that you were doing from this condition was 42.4 (SD ϭ 12.2; range that. Is that something you think happens at home 18–60) years and 60.6% of the sample was fe- as well?” male. Regarding ethnicity, 78.8% of the sample “Are you worried about doing that with me? was White. Because you preface this by saying ‘sometimes I

224 Present-Focused Interventions in CBT for Depression can’t even tell you what’s going on.’” (The client a different set of raters randomly selected from a was talking about draining other people around larger pool of raters was used. Site 1 demon- her with her problems.) strated acceptable reliability (ICC ϭ .75) and Site “Okay. Uh . . . can you put the paper down? 2 demonstrated excellent reliability (ICC ϭ .88). Thanks. Because it’s a . . . it’s a little distracting During the course of the rating project, weekly for me. And it makes me think that what I’m meetings were held to prevent rater drift and saying may not really be picked up by you be- provide corrective feedback. cause you’re not that tuned in to what I’m saying. Not . . . I don’t think that everything I have to say Phase II Coding Procedure is so important, but some things are important and I . . . as long as you’re here I’d like you to Coding. In Phase II, all PF turns of speech kind of take them in. I appreciate that. I know it’s identified in Phase I were categorized into nine not easy for you.” categories. As there were no previous coding “We’re really talking about the hardest thing systems designed for this purpose, categories right now. You know, so it really makes sense to were developed based on a qualitative review of me that you’d feel lousy talking about this.” the treatments described above and a content “Well along those lines, I actually want to analysis of the Phase I codes, and were intended check out . . . if this ties into that. So I’ll do it real to capture the broad themes of present-focused quick right here. I want to keep checking in with work that cut across several treatment ap- you about how you feel about this treatment, does proaches. Four categories derived from the liter- it feel like it’s what you need. . .and about our ature, described below, are ruptures and resis- relationship, the whole thing. How are you feel- tance, present-focused cognitive restructuring, ing about you and me?” comparisons, and disclosure. In addition, the PF Pairs of raters coded DVDs of whole therapy turns of speech identified in Phase I were tran- sessions. Sessions were assigned to rater pairs at scribed according to standard psychotherapy random from the data set. Rater pair assignments transcription guidelines (Mergenthaler & Stinson, rotated weekly so that each rater pair occurred 1992). These PF turns were reviewed by the equally. Kanter et al. (2005) provide evidence for current authors to determine additional categories the validity of the coding system. Using the same necessary to capture the full range of PF content. coding system and coding process, in that study, These additional categories, described below, are as predicted, traditional CT therapists engaged in general process, supportive, direct instruction, very low rates of present-focused interventions as emotion focus, and relationship focus. A final identified by the coding system (turns per session category was included that captured turns that did M ϭ 3.4, SD ϭ 4.9), while FECT therapists, not fit into the above categories and should not trained in present-focus, demonstrated approxi- have been coded as present-focused in Phase I mately triple the rate of present-focused turns per (false positives). This category was labeled not session (M ϭ 9.2, SD ϭ 9.9). present focused. A coding manual (available Raters. Coding occurred at two sites. Raters from the first author) containing descriptions and at Site 1 consisted of 7 undergraduates and 2 hypothetical examples of these nine categories graduate students and raters at Site 2 consisted of was created, and a rater pair categorized turns 10 undergraduates. Training consisted of approx- into these categories using the manual and tran- imately 15 hr of didactic instruction, practice, and scripts of PF turns in each session. Each rater was feedback at both sites. Raters were unaware of instructed to code the transcribed turn. Upon cod- the overall purpose of the study and blind to ing, they were instructed to compare codes, and if treatment condition. To assess interrater reliabil- they disagreed they were to discuss their codes ity, a random subset of 6 raters at Site 1 coded and come to an agreement. three sessions and 10 raters at Site 2 coded four Ruptures and resistance turns were defined to sessions randomly pulled from the larger data set, be consistent with the therapeutic procedures out- and overall agreement between raters was calcu- lined in ICT (Castonguay et al., 2004) and the lated based on the percent of each session iden- other approaches described above. For example, tified as PF by each rater. The formula of intra- this category included therapists pointing out rup- class correlation (ICC) recommended by Shrout tures or resistance in the therapy, inviting clients and Fleiss (1979) when each session is coded by to explore these issues in session, and strategic

225 Kanter attempts to resolve or overcome the rupture or seen as nonspecific present-focused turns and can resistance. An example of a ruptures and resis- be conceptualized as a Rogerian response to cli- tance turn is “You know, you tell me how diffi- ents. An example of a supportive turn is “Good cult life is for you, but when I offer alternatives, job last session. I really have a lot of empathy for you aren’t willing to try any of them.” how difficult that was for you.” Present-focused cognitive restructuring turns Direct instruction turns were defined as turns included therapist attempts to explore and chal- in which the therapist provides direct instructions lenge the client’s thoughts, beliefs, assumptions, to the client during the session or participates in and schemas that were occurring live in the ther- role plays. This occurs in sessions when the therapy session and were related to the therapeutic apist is teaching techniques such as progressive relationship or therapy process. An example of a muscle relaxation (PMR) or assertiveness skills. present-focused cognitive restructuring turn is An example of a direct instruction turn occurring “You could test out that idea or belief that every- during PMR is: “Leave your feet on the floor and one is judging you right now. You could ask me sit back and relax . . . I’ll count and we’ll do the if I’m judging you right now.” breathing together.” These turns were conceptu- Comparisons turns included therapist attempts alized as present-focused because they focus the to compare or contrast situations between the client on what he or she is feeling or doing as it client and the therapist to either current or histor- is happening in the moment. ical situations in the client’s daily life. An exam- Emotion focus turns were defined as turns dur- ple of a comparisons turn is “I think that you ing which the client’s immediate emotions were were really taking responsibility today, when you discussed, without connection to the therapeutic told me what you needed from me in terms of relationship and without specific follow-up. An support. Is that the same kind of thing you need to example of an emotion focus turn is: “What are do with your wife?” you feeling right now as we talk about this?” It is Disclosure turns included therapist self- important to note that if the therapist asked about disclosures to clients about their feelings or the client’s emotions in the context of a discus- thoughts about the client or the client’s behavior. sion of ruptures and resistance, the turn would An example of a disclosure turn is “When you get receive a rupture and resistance code instead. angry and raise your voice, it makes me feel Similarly, asking about the relationship between uncomfortable.” present-focused cognition and affect, which is an General process turns were defined as turns important component of present-focused cogni- dealing directly with the standard therapy pro- tive restructuring (e.g., “When you think that I do cess, including agenda setting, feedback about not like you how do you feel?”) would have what was useful or helpful about the session, received an emotion focus code if there was no asking for or providing a summary of the session, additional restructuring attempted and would goal setting, and getting depression ratings. have received a present-focused cognitive re- These therapist behaviors are explicitly recom- structuring code if there was additional restruc- mended by Beck et al. (1979) and J. Beck (1995) turing attempted. as important strategies to be used in order to Relationship focus turns were defined as ther- establish and maintain structure and continuity apist attempts to discuss the therapy relationship between sessions. They were conceptualized as or feelings toward the therapist that were not present-focused strategies because they focus on specific enough or lacked subsequent follow- what is happening in the moment in the session. through to be coded as any of the above codes. For example, “Can you give me some feedback These turns are expected to occur quite often in on our session today?” requires that the client CBASP, FECT and the other present-focused ap- consider his or her immediate reactions to the proaches as the background on which more spe- session and possibly to the therapist, and the cific present-focused techniques, such as a focus therapist may use this question to explore a PF on ruptures or resistance and present-focused issue in further detail. cognitive restructuring occur. An example of a Supportive turns were defined as turns in relationship focus turn is: “How do you feel which the therapist offers support or otherwise about our relationship?” Like emotion focus lets the client know he or she is supportive in a codes, these codes would not have been used if generally empathic way. Supportive turns may be another specific code was appropriate.

226 Present-Focused Interventions in CBT for Depression

Not present-focused turns were defined as (7.1%), while Dimidjian et al. BA (3.3%) and turns that were not correctly coded during Phase DeRubeis et al. CT (1.9%) demonstrated fewer I and were not considered to be present-focused sessions in this range. The vast majority of turns by the Phase II raters. sessions in all conditions contained 0%–10% PF Raters. Two advanced undergraduate re- turns. The Dimidjian et al. CT condition con- search assistants served as raters and received tained 23.2% of sessions with no present-focused approximately 6 hr of training over the course of turns, the Dimidjian et al. BA condition 2 weeks. Training included didactic instruction contained 42.4% of sessions with no present- by the first author, practice on distinguishing focused turns, and the DeRubeis et al. CT condi- between types of PF turns, and discussion of what tion contained 67.3% of sessions with no present- occurs during a therapy session. Raters were un- focused turns. aware of the overall purpose of the study and Even though PF turns occurred at low rates in were unaware that different treatment conditions all three conditions, it was still possible that sta- existed. To assess reliability, 15 turns were ran- tistically significant differences between condi- domly selected and coded by criterion raters (the tions in the percentage of PF turns would be first and second authors), resulting in 93% agree- found. Another interest in the current study was ment (␬ϭ.92) between criterion and Rater 1, the possibility that the percentage of PF turns 80% agreement (␬ϭ.76) between criterion and would vary depending on when in the course of Rater 2, and 87% agreement (␬ϭ.84) when the therapy the sessions coded took place and on the raters met and agreed on the specific turn. remission status of the clients (nonremitters ϭ HRSD of 13 or high at posttreatment, partial Results remitters ϭ HRSD of 8 to 12 at posttreatment, and full remitters ϭ HRSD of 0 to 7 at posttreat- Phase I ment, as defined by DeRubeis et al., 2005). To Table 1 summarizes the percent of sessions by explore these possibilities, a multilevel growth condition that were coded as present-focused, as curve analysis was conducted using HLM 6.02 well as the percent of total sessions for each (Raudenbush, Bryk, Cheong, Congdon, & du condition in which specific ranges of PF turns Toit, 2004) to determine the effects of treatment were found. PF turns per session occurred at condition and remission status on percent PF similar and very low rates for all three conditions, turns and to model change over the course of with the percent of PF turns falling between 1% therapy (i.e., when in the course of therapy the and 3%. None of the conditions demonstrated a sessions rated took place). This procedure is op- session in which there were more than 30% PF timal because it allows the number and spacing of turns and only the Dimidjian et al. CT condition observations to vary between participants and can had sessions in which there were 20%–30% PF include participants who do not have data for all turns (2.7% of total sessions). Dimidjian et al. CT time points (Raudenbush & Bryk, 2002). The also had more sessions with 10%–20% PF turns final model included a random intercept, a ran-

TABLE 1. Present-Focused Turns per Session by Condition

Dimidjian et al. DeRubeis et Variable BA CT al., CT Total

Turns per session (M, SD) PF turns 1.70 (2.17) 3.36 (4.48) 1.13 (3.22) 2.30 (3.56) Total turns 86.49 (29.73) 98.41 (29.51) 104.09 (35.19) 95.31 (31.49) Percentage PF .02 (.03) .03 (.05) .01 (.03) .02 (.04) Percentage of total sessions with X % of PF turns X ϭ 0–10% 96.7 90.2 98.1 97.4 X ϭ 10–20% 3.3 7.1 1.9 2.3 X ϭ 20–30% 0.0 2.7 0.0 0.3 X Ͼ 30% 0.0 0.0 0.0 0.0 Note. BA ϭ behavioral activation; CT ϭ cognitive therapy; PF ϭ present focused.

227 Kanter dom linear time effect (session position), and 4 fixed between person effects (treatment condi- 3.5 tion, remission status). Results from the growth 3 curve analysis are presented in Table 2. Results 2.5 indicated that, despite overall low rates, treatment DeRubeis CT condition was significantly related to PF turns. 2 Dimidjian BA Dimidjian CT Specifically, the Dimidjian et al. CT condition 1.5 demonstrated a significantly higher percentage of 1 present-focused turns than both the Dimidjian et 0.5 al. BA and DeRubeis et al. CT conditions. On (%) Present-Focused Turns 0 average, therapists in the Dimidjian et al. CT Early Middle Late condition had 1.4% more PF turns than therapists Session Position in the Dimidjian et al. BA condition and 2.3% more PF turns than therapists in the DeRubeis et FIGURE 1. Fitted growth curves for percent present-focused turns as a function of treatment condition. BA ϭ behavioral al. CT condition. This difference can be seen activation; CT ϭ cognitive therapy. graphically in Figure 1. There was no significant time effect. That is, the percentage of PF turns did not differ depending on whether the session the overall codes. As expected, the present- coded was an early, middle, or late session. Fi- focused cognitive restructuring code was also nally, remission status also was not significantly frequently used in both CT conditions and not in related to percent PF turns. the BA condition. The least frequent PF techniques used included focusing on ruptures and Phase II resistance, therapist disclosure, and direct instruction. In terms of miscodes from Phase I, a In Phase II, all PF turns identified in Phase I marginal number of turns were identified as not were categorized into the nine categories de- present-focused. scribed above, as well as the not present-focused code (to identify any miscodes from Phase I). Discussion Because of the exploratory nature of this analysis, these results are presented and described descrip- The broad conclusion from this investigation is tively. The percent and number of PF turns coded that the research therapists in these trials of CT in each category are summarized in Table 3. The and BA for depression rarely focused on the general process and relationship focus codes present moment, and when they did, the focus were the most frequent codes in all three condi- was often transient and lacking in the elaborations, each accounting for roughly one third of tions suggested by newer variants of CBT. Over- all, the percentage of present-focused turns per TABLE 2. Growth Model for Present-Focused Turns per session was very low across all three treatment Session conditions. Occasionally, a session occurred with a significantly higher present focus, particularly Effect Coefficient SE in the Dimidjian et al. CT condition, but no Fixed effects session in any condition evidenced more than ءءء Intercept 0.034 0.007 30% of a focus on the therapy process or therapy 0.005 ءءDimidjian et al. BA Ϫ0.014 relationship. Rates of present-focus found in the ءءء DeRubeis et al. CT Ϫ0.023 0.006 Partial remission Ϫ0.002 0.007 current study were consistent with those found Full remission 0.003 0.006 for traditional CT therapists and much lower than Random effects rates for therapists trained in present-focus Initial status 0.007 (Kanter et al., 2005), suggesting that the system is Linear slope (Session) 0.007 Level I error 0.036 valid and does pick up present-focus when it occurs. Note. Reference group for treatment condition is Dim- In addition, the results of the Phase II analysis idjian et al. CT. Reference group for remission status is No Remission. BA ϭ behavioral activation; CT ϭ cog- suggest that, in the relatively rare instance when nitive therapy. present-focused techniques were applied, the p Ͻ 0.001. techniques more often concerned general therapy ءءء .p Ͻ 0.01 ءء

228 Present-Focused Interventions in CBT for Depression

TABLE 3. Categories of Present-Focused Turns: Percentage (Number) in Each Category by Condition

Dimidjian et al. Variable BA CT DeRubeis et al., CT Total

Ruptures and resistance 1.3 (2) 0.3 (1) 3.6 (2) 0.9 (5) Cognitive restructuring 4.6 (7) 10.7 (40) 23.2 (13) 10.3 (60) Disclosure 0.0 (0) 0.8 (3) 3.6 (2) 0.9 (5) Comparisons 5.9 (9) 2.7 (10) 1.8 (1) 3.4 (20) General process 35.3 (54) 36.3 (136) 28.6 (16) 35.3 (206) Supportive 1.3 (2) 4.5 (17) 1.8 (1) 3.4 (20) Direct instruction 0.0 (0) 0.0 (0) 5.4 (3) 0.5 (3) Emotion focus 7.8 (12) 10.4 (39) 5.4 (3) 9.2 (54) Relationship focus 40.5 (62) 31.2 (117) 25.0 (14) 33.0 (193) Not present-focused 3.3 (5) 3.2 (12) 1.8 (1) 3.1 (18) Note. BA ϭ behavioral activation; CT ϭ cognitive therapy. processes, such as agenda setting or asking for often than that of the other therapists. They dem- feedback about the session, rather than the stra- onstrated fewer opportunities lost compared to tegic applications suggested by the newer ap- the Dimidjian et al. therapists, and higher rates of proaches reviewed in this article. In particular, cognitive restructuring and ruptures and resis- although the cognitive therapists in Dimidjian et tance. This is most likely due to the inclusion in al. (2006) demonstrated significantly higher rates the DeRubeis et al. study of Beck and colleagues of present-focused techniques than did the other (1990) treatment manual on CT for personality therapists, the Dimidjian et al. CT therapists disorders. This manual highlights the importance did not engage in the techniques emphasized as of live cognitive restructuring and resolving dif- important by the newer approaches—ruptures ficulties with the therapeutic alliance (e.g., rup- and resistance, present-focused cognitive re- tures and resistance) for clients with personality structuring, disclosure, and comparisons—to disorders. In fact, all 13 of the present-focused any significant degree or any more than did the cognitive restructuring turns and all 2 of the rup- other therapists. tures and resistance turns identified in that study Instead, our descriptive analysis suggested that occurred with clients with comorbid personality the Dimidjian et al. (2006) CT therapists ap- disorders (PDs). The present-focused cognitive peared to engage in more emotion focus than the restructuring turns occurred in a single session other therapists and in more relationship focus with one client while the ruptures and resistance than the therapists in DeRubeis et al. (2005). turns occurred across four sessions with four cli- These two sets of codes represent what can be ents. Although this is somewhat encouraging, seen as opportunities lost. In other words, these given that a high proportion of clients in that codes were applied when the therapists noticed study received comorbid PD diagnoses (10 of the and commented on an present emotion (emotion 19 clients sampled for the current study received focus) or a live client reaction to the therapist such diagnoses), one may wonder why higher (relationship focus) but did not explore the issue rates of present-focused work did not occur. in depth (indicated by the fact that these codes Although the current research suggests that occurred in isolation and did not repeat for more many present-focused opportunities were lost in than a turn or two) or otherwise follow up on the these studies, more research is needed to demon- opportunity with any of the specific strategies strate that a more intense focus on the present recommended by the newer approaches (indi- moment would improve outcomes in traditional cated by no subsequent present-focused turns forms of CBT. Indeed, even if more is better, it is identified). not clear how much more is better, and the timing The DeRubeis et al. (2005) CT therapists dis- and accuracy of such interventions is undoubt- played a slightly different pattern. While they edly more important than their frequency (Piper, engaged in the least amount of present-focused Joyce, McCallum & Azim, 1993). To date, two techniques overall, the work they did engage in studies have now compared versions of CT tended to include the highlighted strategies more augmented with a present focus to traditional

229 Kanter

CT, with promising results (Constantino et al., demonstrating therapists’ adherence to their re- 2008; Kohlenberg et al., 2002), and two studies spective treatment manuals; therefore the Dimid- have linked present-focused processes (largely jian et al. therapists clearly conducted CT and BA relationship focus) to outcomes (Kanter et al., as indicated by the manuals. Although DeRubeis 2005; Vocisano et al., 2004), but this research et al. did not report such data, it is important to is far from definitive and more is needed in this note that the therapists at one of this study’s sites area. Furthermore, the current study found no (Penn) were considerably more experienced and relationship between the use of present-focused expert in CT than were therapists at the other site interventions and outcome, suggesting that (Vanderbilt). However, post hoc analyses of rates they are not necessary in standard CBT with of present-focused work for each therapist in well-trained therapists. However, this analysis DeRubeis et al. found no indication of therapist was limited by the low rates of present-focused effects in our data—the therapists individually interventions found, the potential high rate of and collectively did not engage in this work to falsely identified present-focused interventions any meaningful degree. Therefore, this data sug- due to the study’s priority to minimize false gests well-trained and adherent CBT research negatives, and the possibility that study thera- therapists do not focus on the present moment. pists engaged in present-focused interventions These therapists had strong backgrounds in CBT with harder clients. Assessing the degree to and were well-trained in the research protocols, which present-focus predicts outcomes will re- so generalization to the larger community re- quire samples in which present-focused inter- mains an open question, as practicing CBT clini- ventions were actually performed at significant cians may be more eclectic and may be more rates and hopefully future research will address likely to include a psychodynamic, interpersonal, this issue. humanistic, intersubjective, or other formulation If future research does suggest that these inter- in their clinical work that addresses the momen- ventions are important, it is important to note that tary interpersonal process to a substantial degree. it is difficult to follow through on present-focused Furthermore, the current research therapists may issues. Live cognitive restructuring, for example, have prioritized adherence to their treatment requires that the therapist, during an emotionally manuals over explorations of the present moment charged interaction with the client, become aware not explicitly described in the manual, as is nec- of his or her own emotional reactions as well as essary for such trials to be internally valid. those of the client, apply a traditional restructur- An additional limitation of the current study is ing intervention, and potentially self-disclose his that only three sessions per client were coded; or her own emotional reactions strategically, gen- thus, important but sporadic present-focused uinely, empathically, and at the proper time. The work easily could have been overlooked. In other complexity of such an intervention may result in words, a focus on the therapy relationship could therapists’ employing it only rarely, even in ap- occur in a small number of sessions, and have a proaches that emphasize such moves. For exam- major impact, rather than continuously across ple, Kohlenberg et al. (2002), in an analysis of many sessions. Furthermore, the current study FECT, found that even after specific training in did not code sessions from clients who prema- FAP’s present-focused interventions, experi- turely terminated treatment; these clients may enced CT therapists engaged in less than ideal have evoked present-focused work at higher fre- amounts of present-focused work in the FECT quencies. Research by Kanter et al. (2005), how- phase of the study. Future research focusing not ever, exhaustively coded every session of every just on whether present-focused work is impor- client in the comparison of CT to FECT (Kohlen- tant, but on how to facilitate the integration of berg et al., 2002) and found rates of present- present-focused work into a therapist’s repertoire, focused work in the CT condition to be very will be helpful. similar to those presented here. A further limita- It is important to discuss the skill level and tion of the study is that a highly inclusive defi- generality of the specific therapists in the current nition of present-focus was used, including basic study compared to the larger community of prac- therapeutic techniques, such as agenda setting, ticing cognitive and behavioral therapists who thus diluting the potential impact of more pow- treat depression. First, Dimidjian et al. (2006), erful present-focused techniques that were also but not DeRubeis et al. (2005), provided data coded. This highly inclusive definition may have

230 Present-Focused Interventions in CBT for Depression played a role in the lack of findings of a signifi- treatments for adult mental disorders. Journal of Con- cant relationship between present-focused resulting and Clinical Psychology, 66, 37–52. sponses and remission. DERUBEIS, R. J., HOLLON, S. D., AMSTERDAM,J.D., SHELTON, R. C., YOUNG, P. R., SALOMON,R.M.,ET AL. The current study adds additional support to (2005). Cognitive therapy vs. medications in the treat- previous research (Castonguay et al., 1995; Gold- ment of moderate to severe depression. Archives of fried et al., 1997, 1998; Kanter et al., 2005) that General Psychiatry, 62, 409–416. suggests that research CBT therapists only rarely DIMIDJIAN, S., HOLLON, S. D., DOBSON, K. S., SCHMAL- ING, K., KOHLENBERG, R. J., ADDIS,M.E.,ET AL. engage in present-focused work. While this con- (2006). Randomized trial of behavioral activation, cog- clusion is becoming increasingly clear, it is by no nitive therapy, and antidepressant medication in the means a criticism of research therapists who are acute treatment of adults with major depression. Jour- trying to adhere to treatment manuals that do not nal of Consulting and Clinical Psychology, 74, 658–670. emphasize present-focused work. However, DOBSON, K. S. (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of Consulting given the increasing number of variants of CBT and Clinical Psychology, 57, 414–419. that emphasize the therapy relationship as an EKERS, D., RICHARDS,D.,&GILBODY, S. (2008). A active mechanism, and compelling albeit still meta-analysis of randomized trials of behavioural treat- preliminary data that such a focus may be ben- ment of depression. Psychological Medicine, 38, 611– eficial (Kanter et al., 2005; Muran, Safran, 623. GELSO,C.,&SAMSTAG, L. (2008). A tripartite model of Samstag, & Winston, 2005; Vocisano et al., the therapeutic relationship. In S. Brown & R. Lent 2004), it does suggest a window of opportunity (Eds.), Handbook of counseling psychology (4th ed.) for potentially increasing the effectiveness of (pp. 267–283). New York: Wiley. CBT, especially for clients for whom tradi- GOLDFRIED, M., CASTONGUAY, L., HAYES, A., DROZD, J., &SHAPIRO, D. (1997). A comparative analysis of the tional CBT has failed. therapeutic focus in cognitive-behavioral and psychodynamic-interpersonal sessions. Journal of Con- sulting and Clinical Psychology, 65, 740–748. References GOLDFRIED,M.,&DAVILA, J. (2005). The role of relationship and technique in therapeutic change. Psycho- American Psychiatric Association. (2000). Diagnostic therapy: Theory, Research, Practice, Training, 42, 421– and statistical manual of mental disorders (4th ed. text 430. revision). Washington, DC: Author. GOLDFRIED, M., RAUE,P.,&CASTONGUAY, L. (1998). BECK, A. T., FREEMAN, A., DAVIS,D.D.,&ASSOCIATES The therapeutic focus in significant sessions of master (1990). Cognitive therapy of personality disorders. New therapists: A comparison of cognitive-behavioral and York: Guilford Press. psychodynamic-interpersonal interventions. Journal of BECK, A. T., RUSH, A. J., SHAW,F.B.,&EMERY,G. Consulting and Clinical Psychology, 66, 803–810. (1979). The cognitive therapy of depression. New York: GORTNER, E. T., GOLLAN, J. K., DOBSON,K.S.,&JA- Guilford Press. COBSON, N. S. (1998). Cognitive-behavioral treatment BECK, J. S. (1995). Cognitive therapy: Basics and beyond. for depression: Relapse prevention. Journal of Consult- New York: Guilford Press. ing and Clinical Psychology, 66, 377–384. BECK, J. S. (2005). Cognitive therapy for challenging HAMILTON, M. (1967). Development of a rating scale for problems: What to do when the basics don’t work. New primary depressive illness. British Journal of Social & York: Guilford Press. Clinical Psychology, 6, 278–296. CASTONGUAY, L. G., HAYES, A., GOLDFRIED,M.,&DE- JACOBSON, N. S., DOBSON, K. S., TRUAX, P. A., ADDIS, RUBEIS, R. (1995). The focus of therapist interventions M. E., KOERNER, K., GOLLAN,J.K.,ET AL. (1996). A in cognitive therapy for depression. Cognitive Therapy component analysis of cognitive behavioral treatment and Research, 19, 485–503. for depression. Journal of Consulting and Clinical Psy- CASTONGUAY, L. G., SCHUT, A. J., AIKINS, D. E., CON- chology, 64, 295–304. STANTINO, M. J., LAURENCEAU, J., BOLOGH, L., ET AL. KANTER, J. W., MANOS, R. C., BUSCH,A.M.,&RUSCH, (2004). Integrative cognitive therapy for depression: A L. C. (2008). Making behavioral activation more behav- preliminary investigation. Journal of Psychotherapy In- ioral. Behavioral Modification, 32, 780–803. tegration, 14, 4–20. KANTER, J. W., SCHILDCROUT,J.S.,&KOHLENBERG, CONSTANTINO, M., MARNELL, M., HAILE, A., KANTHER- R. J. (2005). In Vivo processes in cognitive therapy for SISTA, S., WOLMAN, K., ZAPPERT, L., ET AL. (2008). depression: Frequency and benefits. Psychotherapy Re- Integrative cognitive therapy for depression: A ran- search, 15, 366–373. domized pilot comparison. Psychotherapy: Theory, Re- KELLER, M. B., MCCULLOUGH, J. P., KLEIN, D. N., AR- search, Practice, Training, 45, 122–134. NOW, B. A., RUSH, A. J., NEMEROFF,C.B.,ET AL. CRITS-CHRISTOPH,P.,&BARBER, J. (1991). Handbook of (2000). A comparison of nefazadone, the cognitive be- short-term dynamic psychotherapy. New York: Basic havioral analysis system of psychotherapy and their Books. combination for the treatment of chronic depression. DERUBEIS,R.J.,&CRITS-CHRISTOPH, P. (1998). Empir- New England Journal of Medicine, 322, 1462–1470. ically supported individual and group psychological KLEIN, D. N., SANTIAGO, N. J., VIVIAN, D., ARNOW,

231 Kanter

B. A., BLALOCK, J. A., DUNNER,D.L.,ET AL. (2004). psychotherapy (pp. 95–122). Washington, DC: Ameri- Cognitive-behavioral analysis system of psychotherapy can Psychological Association. as a maintenance treatment for chronic depression. PIPER, W. E., JOYCE, A. S., MCCALLUM,M.,&AZIM, Journal of Consulting and Clinical Psychology, 72, 681– H. F. A. (1993). Concentration and correspondence of 688. transference interpretations in short-term psychother- KOHLENBERG, R. J., KANTER, J. W., BOLLING,M.Y., apy. Journal of Consulting and Clinical Psychology, 61, PARKER,C.R.,&TSAI, M. (2002). Enhancing cognitive 586–595. therapy for depression with functional analytic psycho- RAUDENBUSH,S.W.,&BRYK, A. S. (2002). Hierarchical therapy: Treatment guidelines and empirical ﬁndings. linear models: Applications and data analysis methods Cognitive and Behavioral Practice, 9, 213–229. (2nd ed.). Newbury Park, CA: Sage. KOHLENBERG,R.J.,&TSAI, M. (1991). Functional ana- RAUDENBUSH, S. W., BRYK, A. S., CHEONG, Y. F., CON- lytic psychotherapy: A guide for creating intense and GDON, R., & DU TOIT, M. (2004). HLM6: Hierarchical curative therapeutic relationships. New York: Plenum linear and nonlinear modeling. Lincolnwood, IL: Scien- Press. tiﬁc Software International. LAMBERT,M.,&BARLEY, D. (2001). Research summary SAFRAN,J.D.,&MURAN, J. C. (2000). Negotiating the on the therapeutic relationship and psychotherapy out- therapeutic alliance: A relational treatment guide. New come. Psychotherapy: Theory, Research, Practice, York: Guilford Press. Training, 38, 357–361. SAFRAN,J.D.,&SEGAL, Z. V. (1990). Interpersonal LAZARUS, A. (2003). Some reactions to Robert Kohlen- process in cognitive therapy. New York: Basic Books. berg’s article. The Behavior Therapist, 26, 380. SHROUT,P.,&FLEISS, J. (1979). Intraclass correlations: LEAHY, R. (2001). Overcoming resistance in cognitive Uses in assessing rater reliability. Psychological Bulle- therapy. New York: Guilford Press. tin, 86, 420–428. LEJUEZ, C. W., HOPKO, D. R., LEVINE, S., GHOLKAR, R., TSAI, M., KOHLENBERG, R. J., KANTER, J. W., KOHLEN- &COLLINS, L. M. (2005). The therapeutic alliance in BERG, B., FOLLETTE,W.C.,&CALLAGHAN,G.M. behavior therapy. Psychotherapy: Theory, Research, (EDS.). (2008). A guide to functional analytic psycho- Practice, Training, 42, 456–468. therapy: Awareness, courage, love, and behaviorism in MARTELL, C. R., ADDIS,M.E.,&JACOBSON, N. S. (2001). the therapeutic relationship. New York: Springer. Depression in context: Strategies for guided action. New VOCISANO, C., KLEIN, D. N., ARNOW, B., RIVERA,C. York: Norton, Inc. BLALOCK, J. A., ROTHBAUM, R., ET AL. (2004). Thera- MCCULLOUGH, J. P. (2000). Treatment for chronic depres- pist variables that predict symptom change in psycho- sion: Cognitive behavioral analysis system of psychotherapy with chronically depressed outpatients. Psy- therapy (CBASP). New York: Guilford Press. chotherapy: Theory, Research, Practice, Training, 41, MERGENTHALER,E.,&STINSON, C. H. (1992). Psycho- 255–265. therapy transcription standards. Psychotherapy Re- WADDINGTON, L. (2002). The therapy relationship in cog- search, 2, 125–142. nitive therapy: A review. Behavioural and Cognitive MURAN, J., SAFRAN, J., SAMSTAG,L.,&WINSTON,A. Psychotherapy, 30, 179–192. (2005). Evaluating an alliance-focused treatment for WILLIAMS, J. B. W. (1988). A structured interview guide personality disorders. Psychotherapy: Theory, Re- for the Hamilton Depression Rating Scale. Archives of search, Practice, Training, 42, 532–545. General Psychiatry, 45, 742–747. NEWMAN, C. F. (1998). The therapeutic relationship and YOUNG, J. E. (1999). Cognitive therapy for personality alliance in short-term cognitive therapy. In J. D. Safran disorders: A schema-focused approach. Sarasota, FL: & J. C. Muran (Eds.), The therapeutic alliance in brief Professional Resource Press.

232