Examination of the Skills of Cognitive Therapy for Depression: Evaluating Specificity and Prediction of Differential Response in Cognitive and Behavioral Treatments DISSERTATION Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University By Shannon Nicole Hollars, M.A. Graduate Program in Psychology The Ohio State University 2015 Dissertation Committee: Professor Daniel R. Strunk, Advisor Professor Jennifer S. Cheavens Professor Michael C. Edwards Copyrighted by Shannon Nicole Hollars, M.A. 2015 Abstract Researchers seeking to improve outcomes for Major Depressive Disorder (MDD) have investigated pre-treatment patient characteristics with the goal of identifying treatments or treatment components that might be more effective for some patients than others. Other studies have focused on improving the effectiveness of existing interventions by evaluating the relation of treatment components to outcomes both directly and indirectly via their association with putative therapeutic mechanisms. In the context of cognitive behavioral therapy (also called cognitive therapy (CT)), cognitive and behavioral change procedures and associated cognitive and behavioral changes have been the subjects of a growing body of research (Lorenzo, German, & DeRubeis, 2014). In the current study, I examined whether cognitive and behavioral change procedures were associated with specific changes in patients’ cognitive and behavioral skills. Previous studies have examined the extent that particular components within CT are more effective than others in modifying cognitive and behavioral vulnerabilities but have not found consistent evidence to support the specificity of these changes to CT or components in CT (Jacobson, Dobson, Truax, Addis, & Koerner, 1996). To our knowledge, this study is the first to evaluate skill specificity in the context of the cognitive and behavioral components from CT. In addition, I evaluated pre-treatment ii skills to predict for whom the cognitive and behavioral treatment procedures would be more effective in reducing symptoms and increasing skillfulness. In the current study, a sample of depressed outpatients (n = 42) participated in eight weeks of treatment in which they were randomly assigned to receive either a cognitive only treatment or a behavioral only treatment. Clinicians conducted semi- structured interviews to evaluate patients’ cognitive and behavioral skills at the intake and week eight assessments (Competencies of Cognitive Therapy Scale-Interview; CCTS-I), and self-reported depressive symptom severity was measured at each session using the Beck Depression Inventory-2nd Edition (BDI-II; Beck, Steer, & Brown, 1996). Results of the analyses evaluating the specificity of cognitive and behavioral skill acquisition to these two treatment conditions provided limited support for my prediction. While the estimates suggested that patients in the cognitive treatment improved in cognitive skill more so than patients in the behavioral treatment, this effect was not statistically significant. Treatment was also not significantly predictive of behavioral skill acquisition. In an exploratory set of analyses, I found that treatment was a significant predictor of a measure of skill Specificity, and this effect suggested that patients assigned to the cognitive treatment experienced greater changes in their cognitive skills relative to their behavioral skills than the patients in the behavioral treatment. In examining pre- treatment skills, I found that patients who were more skillful (cognitive or behavioral) at pre-treatment were more likely to experience faster rates of symptom reduction in the behavioral than the cognitive treatment. This effect was significant, regardless of whether cognitive or behavioral skills were evaluated. Finally, I found that more initially iii behaviorally skilled patients experienced greater improvements in this skill when in the behavioral rather than the cognitive treatment. This effect was not significant when evaluating cognitive skills. Treatment group was not associated with differences in patients’ acquisition of cognitive skills. iv Acknowledgments I wish to express my gratitude for the help and support I received in completing this research. I am grateful for the significant contributions and guidance from my advisor, Dan Strunk, and the valuable feedback and suggestions from my committee members, Jennifer Cheavens and Michael Edwards. I am extremely thankful for their time and support throughout this process. I also wish to thank my colleagues in the Depression Research Lab, particularly Andrew Cooper, without whom this project would not have been possible. My project was part of a larger research study which he designed and managed from start to finish. I consider myself to be extremely fortunate to be included in this project and for the unyielding support and encouragement I received throughout this process. Finally, I want to express my love and gratitude for my family and friends, whose support throughout the years has been invaluable to me. I am so thankful for my parents, who have always believed in me and have been an unfailing source of encouragement. You helped me to develop the self-confidence to persist in the face of challenges. Finally, I wish to thank my significant other, Chris, for his support and patience throughout this process. You helped me stay focused and motivated. I could not ask for a more understanding partner. v Vita April 2005 ......................................................Charlotte Catholic High School 2009................................................................B.A. Psychology & English (Summa cum Laude), Emory University 2010 - 2011 ....................................................Graduate Research Associate, Department of Psychology, The Ohio State University 2011 - 2014 ....................................................Graduate Teaching Associate, Department of Psychology, The Ohio State University 2012................................................................M.A., Psychology, The Ohio State University 2012................................................................Doctoral Candidate, Department of Psychology, The Ohio State University 2014 - 2015 ....................................................Graduate Research Associate, Nationwide Center for Advanced Customer Insights, The Ohio State University vi Publications Strunk, D.R., Adler, A.D., & Hollars, S.N. (2013). Cognitive Therapy Skills Predict Cognitive Reactivity to Sad Mood Following Cognitive Therapy for Depression. Cognitive Therapy and Research, 37(6), 1214-1219. Strunk, D.R., Hollars, S.N., Adler, A.D., Goldstein, L.A., & Braun, J.D. (2014). Assessing Patients’ Cognitive Therapy Skills: Initial Evaluation of the Competencies of Cognitive Therapy Scale. Cognitive Therapy and Research, 38(5), 559–569. Fields of Study Major Field: Psychology vii Table of Contents Abstract ............................................................................................................................... ii Acknowledgments............................................................................................................... v Vita ..................................................................................................................................... vi List of Tables .................................................................................................................... xii List of Figures .................................................................................................................. xiv Chapter 1: Introduction ....................................................................................................... 1 Beck’s Cognitive Model.................................................................................................. 5 Skill Acquisition in CT ................................................................................................... 7 Specificity of Skill Change in CT ................................................................................... 8 Measures of Cognitive and Behavioral Change ............................................................ 11 Specificity of Cognitive and Behavioral Change in CT ................................................ 14 Change in CT vs. ADMs. .......................................................................................... 16 CT vs. other psychotherapeutic modalities. ............................................................... 17 Cognitive and behavioral treatment procedures in CT. ............................................. 24 Interpretations of null findings. ................................................................................. 28 Measures of CT Skills ................................................................................................... 29 viii Treatment Matching ...................................................................................................... 34 Relationships between predictors and outcomes. ...................................................... 34 Examination of skills to guide treatment selection. ................................................... 35 What Other Outcomes Should Treatment Matching Studies Seek to Optimize? ......... 40 Purpose .......................................................................................................................... 41 Hypotheses ...................................................................................................................