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Enhancing Cognitive Therapy for Depression 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. Kanter, M a d e l o n Y. Bolling,
a n d C h a u n c e y R. Parker, University o f W a s h i n g t o n
Mavis Tsai, Private Practice, Seattle

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
Functional Analytic Psychotherapy (FAP; tL J. Kohlenberg & Tsai, 1991), a treatment based on a behavioral analysis of the change
process. FAP Enhanced Cognitive Therapy (FECT) includes 7 specific techniques that CT therapists can use to make their treatment
more powerful and to address the diverse needs of clients more effectively. The results indicate that FECT produced a greaterfocus on
the client-therapist relationship and is a promising approach for improving outcome and interpersonal functioning. It also appears
that a focus during sessions on clients 'problematic cognitions about the therapist adds to efficacy.

AVEYOU encountered clients who are resistant to the relationships. He felt people rejected him and he was un-
methods of cognitive therapy (CT), insisting that able to achieve closeness with others. According to Beck
their feelings rule no matter what thoughts they have? Depression Inventory (BDI) scores, he was no longer de-
Have you ever felt, while doing CT, that you would like to pressed at the end of our treatment, and reported mak-
focus more on the client-therapist relationship? Have you ing progress in being more intimate with his wife and
ever wanted to make your treatment more intense and in- children. In this excerpt from the last session, Mr. G. de-
terpersonal, so that the therapy relationship itself is a pri- scribes how he experienced the two types of therapy and
mary vehicle for client change? In this article we describe what he learned:
a treatment for depression that enhances CT so that it ad-
There's a lot of stuff going on in my personal life
dresses the diverse needs of clients and has wider appeal
that we've been working on here in depression and
for both clients and therapists. The enhancements were
so on, and that has led to maybe the cognitive ther-
i n f o r m e d by Functional Analytic Psychotherapy (FAP;
apy way of handling things and looking a t . . . , you
R.J. Kohlenberg & Tsai, 1991), a treatment based on a be-
know, the daily activity log and then doing the
havioral analysis of the process of therapeutic change.
t h o u g h t records and analyzing thoughts and how
Perhaps the experience of Mr. G., a client who re-
they lead to things. So that's over here [with the
ceived both CT and FAP-enhanced CT (FECT), can best
first 8 sessions of CT]. And then on this other part,
describe the qualitative difference between the two ap-
which I definitely got into with you [the second 12
proaches. Mr. G. was a subject in our treatment develop-
sessions o f FECT], was in my personal relationships
m e n t study who received standard CT. When, after the
and how that works, on both sides, myself and the
8th session, his therapist experienced medical problems,
other person. And then it became how that
Mr. G. switched to another therapist (co-author Chauncey
occurred for you and me as an example of [my
Parker) who used FECT for the remaining 12 sessions.
appearing to others as] ominous. It's something I
Obviously there is considerable confounding, but this cli-
learned with you so that it would not persist in
ent was in the unique position of being able to describe
unintentionally coloring my relationships.
and compare his experience of both treatments. Mr. G., a
44-year-old with a long-standing history of major depres- Mr. G. acknowledges the utility of standard CT, which
sion, had not responded to a variety of prior medications he received directly during the first eight sessions and in
and psychosocial treatments. A m o n g his presenting a modified form during the second phase of treatment.
problems was a deep dissatisfaction in his interpersonal Second, he states that during FECT, he became aware, for
the first time, of an interpersonal problem involving
others perceiving something ominous about him that in-
terferes with his relationships. Third, he acknowledges
Cognitive and Behavioral Practice 9, 2 1 3 - 2 2 9 , 2002
1077-7229/02/213-22951.00/0 that this same interpersonal problem that occurred in his
Copyright © 2002 by Association for Advancement of Behavior daily life also occurred in the therapy session between
Therapy. All rights of reproduction in any form reserved. him and his therapist. Finally, he suggests that learning to
214 Kohlenberg et al.

deal with this p r o b l e m with the therapist would help him

in future relationships with others.
(a) A r--> B , > C
T h e m e t h o d s a n d p r o c e d u r e s of FECT are designed to
p r o d u c e the type of therapy e x p e r i e n c e that this client
describes, capitalizing b o t h on the strengths o f CT a n d
on the use o f the t h e r a p e u t i c relationship as a tool for im-
proving interpersonal relationships. D u r i n g this treat- (b) A i > C
merit d e v e l o p m e n t study, we also g e n e r a t e d strategies for
training cognitive therapists to a d d FECT to their reper-
toires, a n d sought to provide a preliminary assessment of
the efficacy o f FECT c o m p a r e d to s t a n d a r d CT. In this
article, we d e s c r i b e FECT t h e o r y a n d t e c h n i q u e s a n d (c) A
p r e s e n t findings from the t r e a t m e n t d e v e l o p m e n t study C
c o m p a r i n g FECT to s t a n d a r d CT.
Figure 1. Some cognition-behavior relationships according to
the FECTexpanded rationale. A = Antecedent Event; B = Belief/
FECT Cognition; C = Consequence (emotional reaction). (a) Repre-
sents the standard cognitive model. (b) Represents a situation in
T h e FECT e n h a n c e m e n t s to s t a n d a r d CT are in- which there is no cognition. (c) Represents a situation in which
t e n d e d to be user-friendly for e x p e r i e n c e d cognitive ther- cognition precedes but is not causally related to the reaction.
apists, a n d rely u p o n the skills, training, forms, proce-
dures, a n d m e t h o d s o f CT. In particular, FECT was built
on the f o u n d a t i o n ofA. T. Beck, Rush, Shaw, a n d Emery's the resulting behavior o r e m o t i o n a l response (A. T. Beck,
(1979) widely p r a c t i c e d a n d empirically validated treat- 1967, p. 322). This is illustrated in Figure 1 (a). Both CT
m e n t for depression. T h e two major FECT enhance- a n d FECT therapists p r e s e n t this s t a n d a r d cognitive hy-
ments to s t a n d a r d CT are (a) the use o f an e x p a n d e d ra- pothesis a n d tell clients that their beliefs, attitudes, a n d
tionale for the causes a n d t r e a t m e n t of depression and thoughts a b o u t external events lead to p r o b l e m a t i c feel-
(b) a greater use o f the client-therapist relationship as an ings a n d maladaptive behavior: t FECT therapists, how-
in vivo teaching opportunity. ever, tell clients that o t h e r possibilities m i g h t also exist in
addition to the A-B-C paradigm. For example, Figure 1 (b)
Enhancement 1: The Expanded Rationale represents the client who says, "I j u s t reacted, I d i d n ' t
T h e e x p a n d e d rationale is based on the behavioral have any p r e c e d i n g thoughts or beliefs." In this case, the
view of cognition a n d its emphasis on historical explana- FECT therapist is m o r e accepting of the idea that there is
tions for c u r r e n t behavior (R.J. K o h l e n b e r g & Tsai, 1991, no cognition at work. Figure 1 (c) represents yet a different
c h a p t e r 5). Cognition is defined as the activity o f think- client who says, "I truly believe that I do not have to be
ing, planning, believing, a n d / o r categorizing. Thus, cog- perfect, b u t I still feel like I have to be." In this case, the
nitions, although covert, are simply behavior. This casts FECT m o d e l a c c o m m o d a t e s the possibility that the client
the often-made distinction between thoughts, feelings, may have a "B" that does not play a role in causing the
and behavior, a n d the primacy of the c o g n i t i o n - b e h a v i o r p r o b l e m a t i c "C," even t h o u g h there is a t e m p o r a l se-
relationship, in a new light: T h e relationship between q u e n c i n g that resembles the o n e posited in the cognitive
cognition a n d behavior becomes a Behavior X - B e h a v i o r hypothesis. That is, the FECT view is that it is possible to
Y relationship, that is, a sequence of two behaviors. Here, have a belief that precedes the p r o b l e m a t i c e m o t i o n
Behavior X is cognition a n d Behavior Y is external behav- a n d / o r behavior but is n o t causally related. T h e r e are
ior o r e m o t i o n a l response. This in turn a c c o m m o d a t e s a several o t h e r variations o f the A-B-C p a r a d i g m that might
variety of possibilities as to the causal c o n n e c t i o n be- also have b e e n i n c l u d e d in Figure 1. F o r example, A-C-B
tween cognition (Behavior X) a n d subsequent behavior would r e p r e s e n t a client who reacts a n d then has a
(Behavior Y). T h e d e g r e e o f control e x e r t e d by cognition thought. For clients whose e x p e r i e n c e matches A-B-C as
over subsequent behavior is on a c o n t i n u u m a n d varies shown in Figure 1 (a), FECT proposes that the m e t h o d s
d e p e n d i n g on the particular client's history. o f cognitive therapy would be maximally effective a n d
This view has implications for the n a t u r e of the ratio- should be used. However, for clients whose e x p e r i e n c e
nale that is p r e s e n t e d to clients in standard cognitive
therapy for depression. For the purposes o f this discus- 1Technically, the term cognition refers to cognitive products, struc-
tures, or processes (Hollon & K~iss, 1984). Due to space limitations,
sion, the cognitive hypothesis is r e p r e s e n t e d as an A-B-C we have not made this distinction here, but we have shown elsewhere
sequence in which A represents an event or stimulus, B that our analysis is consistent with the more technical meanings of
represents cognition in response to A, and C represents cognition (Kohlenberg & Tsai, 1991, chapter 5).
Enhancing Cognitive Therapy 215

corresponds to one of the other paradigms shown in Fig- pie, in comparative outcome studies it is not u n c o m m o n
ure 1, standard cognitive therapy might result in a client- for a percentage of clients to drop out of treatment be-
therapy mismatch and a less effective treatment. It is also cause they feel mismatched to the assigned treatment
possible that multiple paradigms exist for a given client, (Addis, 1995/1996). Addis also reported that mismatches
or that paradigms change from situation to situation. during CT for depression most often occurred because
The use of the e x p a n d e d rationale is illustrated in the the CT rationale did not address the patient's desire to
case of a client, Mr. D. Mr. D. had a problem of getting view their problems as the result of history and experi-
angry too easily. He b r o u g h t up an example of getting an- ence. Similarly, Castonguay, Goldfried, Wiser, Raue, and
gry at other drivers at a four-way stop while driving to his Hayes (1996) f o u n d that when therapists persisted in the
appointment. He explained how the driver in front of application of cognitive techniques despite clients' state-
him could have moved forward a little and allowed Mr. D. ments that the model was not appropriate, the therapeu-
to make a right-hand turn. In this example, the therapist tic a l l i a n c e - - a n d treatment outcomes--suffered. Thus,
does a brief assessment to determine if A-B-C or an alter- the FECT e x p a n d e d rationale is expected to enhance
nate paradigm should also be considered in Mr. D.'s outconle.
Enhancement 2: A Greater Use of the
MR. D.: I thought, "You idiot!"
Client-Therapist Relationship
THERAPIST: You r e m e m b e r during our discussion o f
In FECT, the client-therapist relationship is seen as a
the [FECT] brochure that t h o u g h t sometimes
social environment with the potential to evoke and
precedes feelings but can also occur after. At the
change actual instances of the client's problematic behav-
four-way stop, you thought, "You idiot!" Were you
ior in the here and now (Follette, Naugle, & Callaghan,
aware as to whether you had that t h o u g h t first and
1996; R.J. Kohlenberg & Tsai, 1991). For example, a cli-
then got angry, or did you get angry first and then
ent who doesn't express anger in his daily life because he
have the thought?
assumes terrible things will h a p p e n if he does, might get
MR. D.: I got angry first.
angry at the therapist but not express this anger because
Although the standard cognitive hypothesis states that of his assumption. In FAP terminology, the client's as-
depressogenic schemas acquired developmentally create sumption about the therapist is referred to as Clinically
a vulnerability to depression, the FECT expanded ratio- Relevant Behavior (CRB), an actual here-and-now occur-
nale increases the emphasis on historical factors more rence, in the therapy session, of daily life problematic
broadly defined, to account for the client's reactions to thinking or behavior. According to FAP theory, there are
the world either along with or as an alternative to the A-B-C extraordinary opportunities for significant, therapeutic
hypothesis. This is consistent with a behavioral analysis of change when CRBs occur and are recognized by the ther-
problems, tracing causality to external sources occurring apist. The therapist who notices CRB will be more likely
in the reinforcement history of the individual (R. J. to shape immediately, encourage, and nurture improve-
Kohlenberg & Tsai, 1991). Although changing cognitions ments in vivo (R.J. Kohlenberg & Tsai, 1991, chapter 2).
is often a successful therapeutic strategy, it is sometimes Accordingly, several specific FECT techniques are de-
advantageous to take an historical view of how the prob- signed to increase therapist awareness of CRBs. It should
lem developed. Recognizing historical antecedents that be noted that CRBs are real, they occur naturally during
account for clients' problems and their negative cogni- therapy, and they differ from the p r o m p t e d a n d / o r
tions gives them a way to explain their behavior to them- scripted within-session behaviors of role-playing, behav-
selves that may be less blaming than cognitive explana- ioral rehearsal, or social skills training (R. J. Kohlenberg,
tions by themselves. Tsai, & Dougher, 1993).
The expanded rationale is expected to improve the The FECT use of the client-therapist relationship as an
match between client and treatment. As recently pointed in vivo learning opportunity is based on a well-known
out in this journal (Addis & Carpenter, 2000), clients who property of reinforcement: The closer in time and place
respond favorably to the treatment rationale in CT for a behavior is to its consequences, the greater will be the
depression are more likely to improve following treat- effect of those consequences. It follows, then, that treat-
m e n t (Addis 1995/1996; Addis &Jacobson, 1996; Fennel m e n t effects will be stronger if clients' problem behaviors
& Teasdale, 1987; Teasdale, 1985). Addis and Carpenter and improvements occur during the session, as they are
hypothesize that the match between the client and the closest in time and place to the available reinforcement
treatment rationale promotes more favorable outcome from the therapist. Rather than only talking about the cli-
due to such factors as increased rapport, therapeutic alli- ent's problems, the therapist can effect positive change as
ance, and willingness to do homework. O n the other behaviors occur. Goldfried (1985) described these spe-
hand, a mismatch can have deleterious effects. For exam- cial opportunities as "in vivo" cognitive behavioral work
2.16 Kohlenberg et al.

and noted that situations when these opportunities occur Generalization From Treatment to Daily Life
are "more powerful than imagined or described" situa- As therapy progresses, clients display more CRB2s (im-
tions (p. 71). The same idea is found in the widely ac- provements in session). As discussed in R.J. Kohlenberg
cepted notion that in vivo exposure treatment is more and Tsai (1991), generalization of improvements from
powerful than in-office treatment. This FAP view of the the client-therapist interaction to daily life is expected to
client-therapist relationship differs both from the notion occur naturally but can be augmented by offering inter-
of collaboration in cognitive therapy and from therapeu- pretations that compare within-session interactions to
tic alliance (Callaghan, Naugle, & Follette, 1996; Follette daily life. For example, the therapist might say, "Your be-
et al., 1996; B. S. Kohlenberg, Yeater, & Kohlenberg, lief that I will do something terrible to you if you criticize
1998). Although there are thndamental theoretical dif- the therapy seems to resemble the belief you have about
ferences between FAP and psychoanalysis (see R. J. others in your life." Successful within-session hypothesis
Kohlenberg & Tsai, 1991, chapter 7), the notion of CRBs testing and consequent m o o d improvement would simi-
as special opportunities for therapeutic change has much larly be related to uses in daily life. Standard CT home-
in c o m m o n with the psychoanalytic concept of working work assignments can be built from this in vivo work. For
with transference (R.J. Kohlenberg & Tsai, 1994). example, the therapist may say, "Now that you have found
that your belief--that I will respond poorly to you if you
The Two Main Forms of Clinically Relevant Behavior: express your feelings directly to m e - - i s inaccurate, do
CRB1 and CRB2 you think a good homework assignment would be to
The use of the therapeutic relationship depends on check out that belief with your wife?"
the therapist's ability to recognize the client's problems
as they occur in session. Such problematic behavior is Putting the Enhancements Into Practice:
termed CRB1. Equally important is the therapist's ability Seven Specific Techniques
to recognize improvements as they occur in-session. IYeatment occurs simultaneously on two levels. At the
These improvements are termed CRB2. first level, FECT therapists conduct A. T. Beck and col-
leagues' (1979) CT for depression. Beck's CT consists of
Problematic Cognitive and Interpersonal Behaviors a 20-session structure and specific procedures such as (a)
as CRBs defining and setting goals, (b) stnmturing the session
CRBls and CRB2s (problems and improvements in (setting and following an agenda; eliciting feedback from
the here and now) may be cognitive behavior a n d / o r in- the client at the end of the session), (c) presenting a ra-
terpersonal behavioi: Cognitive CRBs are in-session, ac- tionale, and (d) using cognitive-behavioral strategies and
tual occurrences of problematic cognition (thinking, as- techniques. The FECT therapist, however, uses the ex-
suming, believing, perceiving). In the example of Mr. D., panded rationale rather than the standard CT rationale.
the angry client, the client's assumption that "the thera- This requires the flexibility to drop the A-B-C hypothesis
pist will do something terrible if I express my anger" is a if it does not match the client's experience a n d / o r if the
problematic in-session cognition. The occurrence of a client is not progressing.
problematic cognitive CRB provides a special opportu- The second level of therapy is perhaps the most im-
nity for the therapist to do in vivo CT. For example, the portant. At the same time that the above technical proce-
therapist could use a thought log or empirical hypothesis- dures are used, FECT therapists are observing the client-
testing pertaining to the here-and-now client-therapist in- therapist interaction and looking for the client's daily life
teraction. Cognitive CRBs are also identified as having problems and dysfunctional thoughts actually occurring
special significance in the CT variants of Young (1990) in the here and now, within the context of the client-
and Safran and Segal (1990). therapist relationship. The following seven techniques
The angl y client example involved both cognitive and highlight the FECT approach and help the therapist to
interpersonal CRBs. Interpersonal CRBs are actual in- work on both levels.
session problematic interpersonal behavior. One CRB1
may have been that the client did not express his angry 1. Setting the Scene Early
feelings toward the therapist. The therapist could have en- The FECT interest in history and observation of in
couraged or p r o m p t e d the client to express his anger in- vivo client behavior is established early. Either before
stead of employing the in vivo cognitive intervention (e.g., treatment begins or during the first session of FECT, cli-
the thought log) if such expression is conceptualized as a ents are given the following assignment: "Write an outline,
CRB2, or improvement in client behavior. This points up a time chart, or an autobiography of the main events, en-
the importance of generating a clear case conceptualization during circumstances, highlights, turning points, and re-
from the outset and updating it as treatment progresses. lationships that have shaped who you are as a person,
(Case conceptualization is outlined below.) from your birth to the present time." T h e assignment
Enhancing Cognitive Therapy 217

indicates to the client that the therapist is interested in lar response not an instance of the client's daily life prob-
history. At another level, it gives the therapist an opportu- lems? This process of noticing potential CRBs is essential
nity to observe how the client deals with this task (e.g., to FECT, and is sharpened by the use of the case concep-
procrastinates, gives sparse information, completes vol- tualization form as discussed below.
umes of writings, assertively refuses to do it) and helps
generate hypotheses about potential CRBs that might ap- 3. Use Case Conceptualization as an Aid
pear in therapy. Both the historical information and the to Detecting CRB
hypothesized CRBs enter into the formulation of an ini- In FECT, case conceptualization is the sine qua n o n of
tial case conceptualization as described below. therapeutic work. It is in fact a functional analysis of rele-
vant client behaviors (thinking and feeling in addition to
2. Present the Expanded Rationale and Elicit Feedback physical and verbal events). As discussed in R.J. Kohlen-
Underscoring FECT's inclusion of CT, the therapist berg and Tsai (2000), FECT case conceptualization serves
presents a treatment rationale to the client in the form of three purposes. First, it generates an account of how the
two brochures, the Beck Institute's "Coping With Depres- client's history resulted in the current daily life problems.
sion" (A. T. Beck & Greenberg, 1995) and the FECT bro- It includes an explanation of how current problem be-
chure (R. J. Kohlenberg & Tsai, 1997). "Coping With haviors were adaptive at the time they were acquired, and
Depression" presents the cognitive hypothesis, a prelimi- sets the scene for the client to learn new ways of behav-
nary oudine of types of thinking errors depressed people ing. Second, it identifies possible cognitive p h e n o m e n a
c o m m o n l y make, and a brief overview of the direction of that might be related to current problems. Third, and
treatment. The FECT brochure acknowledges the A-B-C most importantly, FECT case conceptualization identifies
hypothesis and the value of learning new ways to think. It and predicts how clinically relevant behavior--daily life
also allows for the possibility that the A-B-C paradigm problems (including dysfunctional thinking; CRB1) and
might not always match the particular client's experience improvements ( C R B 2 ) - - m i g h t occur during the session
and discusses alternative paradigms. For example, the within the client-therapist relationship. Hence, the case
brochure states, conceptualization helps therapists notice CRBs as they
occur and to use these opportunities to shape and rein-
The focus of your therapy will d e p e n d on the
force improvements in vivo.
causes of your problems. Thus, along with cognitive
The FECT case conceptualization form is a working
therapy, your treatment might also include: explor-
d o c u m e n t to help maintain a focus on the goals of ther-
ing your strengths and seeing the best of who you
apy and increase therapist detection of in-session prob-
are; grieving your losses, contacting your feelings,
lematic thinking and behavior and their improvements.
especially those that are difficult for you to experi-
The form is filled out as soon as there is e n o u g h informa-
ence; developing relationship skills; developing
tion. Sometimes it is filled out jointly with the c l i e n t - - a t
mindfulness, acceptance and an observing self;
the very least, it is presented to the client for feedback,
gaining a sense o f mastery in your life.
and modified t h r o u g h o u t the course of therapy as more
The FECT brochure emphasizes focusing on the here information is gathered. A more detailed description of
and now and using the client-therapist relationship to this form and its application can be f o u n d in R.J. Kohlen-
learn new patterns of behavior. A more detailed descrip- berg and Tsai (2000). A description of the form's six col-
tion of the FECT rationale can be f o u n d in R.J. Kohlen- umns follows.
berg and Tsai (2000). Daily life problems. These are the client's complaints.
Presenting the rationale is a critical juncture in ther- For example, Mr. G. complained of a lack of close rela-
apy and must be accompanied by therapist observation of tionships and rejection by others.
how the rationale is received by the client, what parts of it Relevant history. History refers to childhood and signif-
elicit particular enthusiasm, or what parts elicit some dis- icant events over the life span, or more recent experiences
agreement. Because the FECT expanded rationale is flex- that account for the thinking, actions, and meaning that
ible, client feedback is important to help determine the may be implicated in daily life problems. The purpose of
course of therapy or the particular type of interventions this column is to generate an explanation of how the cur-
to be used. At the same time, all client reactions are rent problems were learned and how they were adaptive
viewed as potential CRBs. For example, a female client at the time they were acquired. Historical interpretations
may say, "That's fine, whatever," in reaction to the bro- set the scene for the client to learn new ways of behaving.
chures. What's going on in this case? Is this the way the For example, Mr. G. reported a family environment that
client deals with others, as well--accepting whatever is severely punished warmth and vulnerability.
dished out? Is she afraid to express her real reaction to Corresponding in-session problems (interpersonal/behavioral
the therapist, just as she is with others? Or is this particu- CRBls). It was hypothesized that Mr. G. would act in ways
218 K o h l e n b e r g e t al.

t h a t w o u l d i n t e r f e r e with f o r m i n g a close r e l a t i o n s h i p p r e s e n t s several c o r e beliefs i d e n t i f i e d by J. S. Beck

with the therapist. It was in this c o n t e x t that MI: G.'s "om- (1995), a l o n g with c o r r e s p o n d i n g CRBs that can b e antic-
inous" style o f i n t e r a c t i n g was i d e n t i f i e d by t h e therapist. ipated from them.
This style e m e r g e d w h e n the t h e r a p i s t was o p e n a n d ex- Intimacy CRBs. At the b e g i n n i n g o f therapy, F E C T
p r e s s e d w a r m t h toward Mr. G. therapists tell t h e i r clients that w h e n they can express
Corresponding cognitive concepts (cognitive CRBls: auto- t h e i r t h o u g h t s , feelings, a n d desires in an a u t h e n t i c , car-
matic thoughts, core beliefs, underlying assumptions). Mr. G. ing, a n d assertive way, they will be m o r e likely to find j o y
h a d t h e c o r e b e l i e f that h e was defective. in life a n d to be less 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
Daily life goals, ME G.'s goals w e r e to b e less d e p r e s s e d 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 to b u i l d t h e s e skills be-
a n d to have m o r e i n t i m a c y in his relationships. cause the therapist can offer the c l i e n t s o m e t h i n g that n o
In-session goals (CRB2s). T h e s e are i m p r o v e m e n t s in o n e else can in the s a m e way: p e r c e p t i o n s o f w h o t h e cli-
the client-therapist r e l a t i o n s h i p . Mr. G., for e x a m p l e , e n t is, ways in which the client is special, a n d ways in
d e m o n s t r a t e d i m p r o v e m e n t by b e i n g v u l n e r a b l e w h e n w h i c h the c l i e n t impacts t h e therapist, T h r o u g h o u t ther-
h e said, "I d o n ' t w a n t to a p p e a r o m i n o u s now," after the apy, e m p h a s i s is p l a c e d o n the c l i e n t b e i n g able to ex-
t h e r a p i s t told h i m that h e c a r e d a b o u t a n d liked Mr. G. press w h a t is difficult for h i m o r h e r to express to the
T h e t h e r a p i s t a c k n o w l e d g e d the i m p r o v e m e n t a n d con- therapist. Q u e s t i o n n a i r e s given to the client at the b e g i n -
f i r m e d that 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 be- ning, m i d d l e , a n d e n d o f t h e r a p y (see Table 2 for s a m p l e
cause o f Mr. G.'s CRB2. H y p o t h e s i z i n g in a d v a n c e o n the q u e s t i o n s ) e n c o u r a g e the c l i e n t to say w h a t is g e n e r a l l y
case 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 CRB2s that m i g h t oc- difficult to say, w h e t h e r they b e criticisms, fears, longings,
c u r h e l p s t h e t h e r a p i s t to be p r e p a r e d for t h e i r e m e r - o r a p p r e c i a t i o n . F E C T therapists m o d e l i n t i m a c y skills
g e n c e a n d to be in a b e t t e r p o s i t i o n to n u r t u r e a n d s h a p e for clients by e x p r e s s i n g caring, e x p r e s s i n g feelings, tell-
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 if a n d w h e n it ing clients what they see as t h e i r strengths, talking a b o u t
does happen. c o n c e r n s in a way that validates them, a n d m a k i n g r e q u e s t s

4. N o t i c e CRBs: 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
Based o n the case c o n c e p t u a l i z a t i o n , F E C T therapists Table 2
h y p o t h e s i z e a b o u t a n d l o o k for specific CRBs. A few o f Sample Beginning, Middle, and End of Therapy
the m o s t c o m m o n d o m a i n s follow. Questionnaire Items*
Cognitive CRBs. I m p o r t a n t cognitive CRBs can he Beginning of Therapy
i d e n t i f i e d by e x a m i n i n g the client's c o r e beliefs, w h i c h I notice these similarities and differences between my usual style
are i d e n t i f i e d in the c o u r s e o f s t a n d a r d CT. C o r e beliefs of beginning and how I am beginning this relationship...
can be translated i n t o cognitive CRBs, a n d this will facili- I will increase the likelihood of having a good experience and
getting what I want from therapy i f . . .
tate the therapist's awareness o f t h e i r p o t e n t i a l . Table 1
Middle of Therapy
I'm having a hard time expressing myself a b o u t . . .
I want you to know...
Table I It would be difficult for me to f a c e . . .
Potential Core Beliefs and Corresponding Anticipated CRBs I am interested in changing my therapy to include...
I could improve our relationship b y . . .
Core Issue Anticipated CRB Yon could improve our relationship b y . . .
I have a hard time expressing myself a b o u t . . .
Alone Feels this way, even with therapist. It is hard for me to tell you a b o u t . . .
Defective As seen by therapist. What bothers me about you i s . . .
Different As seen by therapist or in reactions to
therapy. End of Therapy
Doesn't nleasure up As seen by therapist. For many clients, the end of therapy brings up feelings and
Failure In therapy. With therapy tasks, memories of previous transitions and losses. What thoughts
homework. and feelings do endings in general bring up for you?
Helpless In relation to therapist, can't influence What thoughts and feelings are you having about the ending of
therapist. this therapy relationship?
Inadequate To understand the therapy, to get better What have you learned, what has been helpful for you in this
with this treatment. therapy?
Incompetent In therapy. What stands out to you most about yonr interactions with your
Ineffective In therapy. therapist?
Inferior To therapist, to other clients. What do you like and appreciate about your therapist?
I,oser In relation to therapist, as seen by What regrets do you have about the therapy or what would you
therapist, to be in therapy. like to have gone differently?
Loser (in relationships) In therapy relationship.
* Adapted ti-om Bmcknm=Gordon, Gangi, and Wallman (1988).
Enhancing Cognitive Therapy 219

(I want, I need, I would like). FECT therapists also model 6. Increase Therapist Self-Awareness as an Aid to
self-disclosure when it is in the client's best interest (i.e., Detecting and Being Aware o f CRBs
when relevant to the client's issues, offering support, un- FECT therapists use their personal reactions to alert
derstanding, e n c o u r a g e m e n t , hope, a n d the sense that them to client CRBs. T h e more therapists are aware of
the client is n o t alone). a n d u n d e r s t a n d their own reactions to their clients, the
Avoidance CRBs. From a behavioral viewpoint, avoid- easier it will be for them to detect CRBs a n d r e s p o n d ap-
ance is o n e of the major factors in the etiology a n d main- propriately. For example, d u r i n g supervision co-author
t e n a n c e of depression (Ferster, 1973), a n d avoidance Mavis Tsai noticed that in a tape of a session, when a cli-
CRBs are often a target in FECT. For many clients, thera- e n t expressed warmth a n d appreciation toward the ther-
peutic change is facilitated when avoidance is gently apist, the therapist c h a n g e d the subject without acknowl-
blocked a n d clients are e n c o u r a g e d to take risks outside edging what the client had said. Dr. Tsai also noticed that
of their usual comfort zone both in the session a n d in this therapist t e n d e d to be u n c o m f o r t a b l e when Dr. Tsai
daily life. For example, a client remains silent for a mo- c o m p l i m e n t e d him. W h e n this was p o i n t e d out, the ther-
m e n t a n d looks troubled in response to a question. W h e n apist became more aware of this discomfort a n d focused
the therapist inquires further, the client says, "Oh, I d o n ' t on b e i n g more receptive a n d reinforcing when compli-
know, n o t h i n g important." This may be a CRB1. That is, m e n t e d . Subsequently, he was better able to detect a n d
in daily life, the client may avoid talking a n d feeling naturally reinforce positive interpersonal behaviors of his
a b o u t troubling topics by using such dismissive phrases. clients. Table 4 presents sample questions that can be
This type of CRB1 precludes the possibility of the client's used d u r i n g supervision of FECT therapists to increase
resolving the issue that she or he is avoiding, a n d inter- self-awareness related to provision of FECT.
feres with f o r m i n g more satisfying relationships. Gentle
inquiry into " n o t h i n g important" may p r o m p t CRB2s, 7. Use the Modified T h o u g h t Record
which, in this case, may be the client identifying a n d ex- We modified the thought record (A. T. Beck et al., 1979,
pressing his or h e r feeling of discomfort to the therapist. p. 403) used during CT in the following ways. First, the in-
The therapist should take care that his or her response to structions were modified to include the expanded ratio-
the CRB2 will naturally reinforce the new behavior. This nale: The client is asked to consider whether the A-B-C, A-C,
may involve risk-taking a n d real e m o t i o n a l involvement or A-C-B paradigms fit his or her particular experiences.
o n the part of the therapist, so the therapist should also
Begin filling out this record with the problematic
be aware of his or her own avoidance CRBs.
situation, what you did, or what you felt. If possible,
denote whether the thinking, feeling, or d o i n g
5. Ask Questions to Evoke CRBs
came first, second, or third (which did you experi-
FECT therapists ask questions that b r i n g the client's
ence first, second, a n d third?).
attention to their thoughts a n d feelings at the m o m e n t
a b o u t the therapy or therapeutic relationship. Table 3 Second, a new c o l u m n , "In Vivo," has b e e n added to
presents several useful questions of this type. the form to facilitate the therapist-client focus. After

Table 4
Table 3 Sample Questions for Use During Supervision of FECTTherapists
Useful Sample Questions to Evoke CRB to Increase Self-Awareness

What's your reaction t o . . . what I just said? What thoughts and feelings is the client stirring up in you?
to the rationale I just gave? How can these reactions help/hinder the client or the therapy?
to me as your therapist? What does this tell you about the client?
to agenda setting? What does this tell you about yourself?.
to structured therapy? What are your own CRBls and CRB2s in relationships and
to the homework assignment? particularly as they pertain to your work with this client?
to time-limited 20-sessiontherapy? What would be helpful to the client and also promote better
What were you thinking/feelingon your way to therapy today? therapist behavior? What do you uniquelybring to the therapy
What are your behaviors that tend to bring closeness in your relationship?
relationships? How do you think the waysyou've been hurt emotionally shaped
What do you tend to do that decreases closeness in your who you are (your behavior) as a therapist, both positivelyand
relationships? negatively?
How would you feet about us watching for your behaviors in here In general, what do you think your strengths and weaknesses are as
which increase or decrease closeness? a therapist?
What were yon thinking/feelingwhile you were waiting for me out What concerns and apprehensions do you have as you begin seeing
in the waiting room? FECT clients?
220 Kohlenberg et al.

d e n o t i n g the thoughts, feelings, a n d actions that oc- ticipants interviewed, 49 m e t full eligibility criteria and
c u r r e d in response to the particular event in daily life, the were a c c e p t e d into the study. T h r e e participants d r o p p e d
client is asked, "How might similar p r o b l e m a t i c thoughts, before therapist assignment; 46 participants were as-
feelings, a n d / o r actions c o m e up in session, a b o u t the signed to either CT (18 clients) or FECT (28 clients) and
therapy, o r between you a n d your therapist?" started therapy. Two additional clients (one CT a n d o n e
Third, a new column, "Alternative, More Productive FECT) were r e m o v e d from the study after therapy began.
Ways o f Acting" asks clients to come up with alternative O n e was d u e to a therapist medical e m e r g e n c y a n d o n e
ways of acting that would help t h e m achieve their goals. was due to the e m e r g e n c e o f a severe personality d i s o r d e r
T h e client is also asked to rate his o r h e r " C o m m i t m e n t to missed d u r i n g screening. Participants' m e a n age was
Act More Effectively" using the following scale: 41.69 + 9.61; 64% were female, 38.5% were m a r r i e d o r
living with s o m e o n e , a n d 46% had g r a d u a t e d from a
0% N o n e (I can't act b e t t e r while I have nega-
4-year college.
tive thoughts a n d / o r feelings).
50% I am willing to give it a try.
100% Very much. I will act effectively a n d have my
O u r research therapists h a d b e e n in practice for at
negative thoughts a n d feelings at the same
least 10 years a n d h a d served as cognitive therapy re-
search therapists on p r i o r clinical trials. T h r e e therapists
Based on acceptance (Hayes, Strosahl, & Wilson, 1999; were psychologists; o n e was a social worker. Two thera-
Linehan, 1993) a n d behavioral activation (Jacobson et al., pists were b o a r d certified by the A c a d e m y o f Cognitive
1996; Martell, Addis, & J a c o b s o n , 2001) approaches, this Therapy.
c o l u m n can be used to raise the issue that it is possible
to i m p r o v e even if o n e has negative thoughts a n d feel- Procedure
ings. This a p p r o a c h is particularly usefifl for h e l p i n g cli- Standard CTphase. Each therapist was instructed to do
ents who d o n o t i m p r o v e with s t a n d a r d cognitive the> 20-session CT for depression, using A. T. Beck a n d col-
apy i n t e r v e n t i o n s o r for those who reject the cognitive leagues (1979) a n d J. S. Beck (1995) as manuals. T h e
hypothesis. therapists m e t for weekly g r o u p supervision meetings. DI.
These seven specific techniques i n c o r p o r a t i n g two S a n d r a Coffman, an e x p e r i e n c e d cognitive therapist who
m a i n e n h a n c e m e n t s to CT were tested in the course of a served as a research therapist on two p r i o r clinical trials,
3-year study. a t t e n d e d a b o u t 50% o f the g r o u p meetings d u r i n g the
CT phase a n d provided individual CT supervision. Addi-
tionally; Dr. Keith Dobson rated foul" sessions from each
Empirical Findings
therapy case for c o m p e t e n c y on the Cognitive T h e r a p y
Depressed subjects were sequentially assigned, in Scale (Dobson, Shaw, & Vallis, 1985; Vallis, Shaw, & Dob-
waves, to each o f four e x p e r i e n c e d cognitive therapists. son, 1986) a n d o n g o i n g f e e d b a c k based on these ratings
D u r i n g the first 6 m o n t h s of the study, 18 subjects were as- was proxdded to the therapists.
signed to CT a n d received standard CT tor depression. In PECT phase. T h e same four therapists began FECT
the 7th m o n t h , FECT began a n d the next 28 subjects t r e a t m e n t d u r i n g the second year o f the study. Training
were sequentially assigned in waves to the same f o u r in FECT consisted of a 6-hour workshop a n d weekly
therapists. g r o u p a n d individual supervision from Dr. K o h l e n b e r g or
Dr. Tsai. T h e t r e a t m e n t manuals for this phase consisted
of the two CT books (A. T. Beck et al., 1979; J. S. Beck,
1995), the FAP b o o k (R.J. K o h l e n b e r g & Tsai, 1991), and
Clients s u p p l e m e n t a l FECT materials, such as the questions in
Eligibility criteria were a diagnosis of major depressive Tables 1 t h r o u g h 4 a n d forms c o m m o n l y used in CT that
d i s o r d e r a c c o r d i n g to the Structured Clinical Interview were modified to be consistent with FECT.
for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams,
1995) a n d a score of 18 o r greater on the Beck Depres- Measures
sion Inventory (BDI; Beck, Ward, Mendelson, Mock, & We wanted to measure several different classes o f vari-
E r b a u g h , 1961). E x c l u s i o n c r i t e r i a were t h e s a m e as ables in this study. First, we wanted o u r study to be compa-
J a c o b s o n et al. (1996). rable to t r a d i t i o n a l o u t c o m e studies o n t r e a t m e n t for
Participants were recruited t h r o u g h c o m m u n i t y clinic depression, so traditional o u t c o m e measures were used
referrals a n d newspaper advertisements. After an initial (e.g., Elkin et al., 1989). We used (a) the 17-item Hamil-
p h o n e screening, participants were given a full diagnostic ton Rating Scale for Depression (HRSD; Hamilton, 1967);
evaluation to d e t e r m i n e study eligibility. O f the 116 par- (b) the Global Assessment of F u n c t i o n i n g Scale ~GAF;
222 Kohlenberg et al.

Table 5 u r e s as t h o s e w i t h less t h a n a 25% r e d u c t i o n

Mean Scores on Major Outcome Variables by Condition, p Values and Effect Sizes in s y m p t o m s . F i g u r e 3 s h o w s t h e p e r c e n t a g e

CT FECT o f f a i l u r e s in C T a n d F E C T f o r e a c h out-
c o m e m e a s u r e . F E C T h a d f e w e r failures t h a n
Time N M + SD N M +- SD p ES d i d CT o n all m e a s u r e s .
Remission. D e f i n i n g r e m i s s i o n at t h e e n d
BDI Pre 15 21.67 +- 8.09 23 21.65 +- 5.36
Post 15 10.67 +- 10.03 23 8.61 -+ 5.45 .20 .28 o f t r e a t m e n t as H R S D 6 o r less, F E C T pa-
Follow-up 15 8.87 + 7.43 23 7.83 -+ 4.76 .30 .17 d e n t s s h o w e d a n i n c r e m e n t a l i n c r e a s e in re-
HRSD Pre 15 14.93 +- 4.06 23 14.65 -+ 3.75 m i s s i o n o f 67%. E i g h t e e n o f 23 (78.3%)
Post 15 8.60 + 7.12 23 5.52 -+ 4.54 .O6 .53 F E C T p a t i e n t s r e m i t t e d c o m p a r e d to 46.7%
Follow-up 15 4.47 + 4.24 23 4.04 -+ 3.69 .40 .08 ( 8 / 1 5 ) o f C T clients (X2 = 4.03, p = .049).
SCL-90 Pre 15 0.92 -+ 0.42 23 0.89 +- 0.35 D i f f e r e n c e s in r e m i s s i o n rates d e f i n e d as
Post 11a 0.54 -+ 0.42 18b 0.35 -4- 0.20 .06 .61 BDI 8 o r less w e r e n o t statistically s i g n i f i c a n t
Follow-up 13c 0.66 + 0.37 17a 0.46 + 0.43 .10 .48 b e t w e e n c o n d i t i o n s . It is n o t c l e a r as to why
GAF Pre 15 54.67 +- 5.23 23 55.09 -+ 7.82 reliable d i f f e r e n c e s in r e m i s s i o n w e r e f o u n d
Post 15 70.27 +- 15.52 23 73.13 +- 13.79 .29 .19 only with t h e H R S D c r i t e r i o n .
Follow-up 15 78.87 +- 11.42 23 85.39 +- 9.52 .03 .65
Relapse analyses. S i n c e we o n l y h a d a 3-
Note. p = p value for between condition ANCOVA; ES = Effect size; BDI = Beck Depression m o n t h f o l l o w - u p a s s e s s m e n t , o u r analyses o f
Inventory; HRSD = 17-item Hamilton Rating Scale for Depression; SCL-90 = Symptom r e l a p s e w e r e b a s e d o n this l i m i t a t i o n . We
Check-List 90, total score; GAF = Global Assessment of Functioning. l o o k e d at s u s t a i n e d remission r a t e s (SR; H o l -
aFour CT clients did not return their post-treatment assessment packets (which included the
Ion, 2001) at t h e 3 - m o n t h follow-up. A c l i e n t
SCL-90 and SAD).
b Five FECT clients did not return their post-treatment assessment packets (which included was in SR i f h e / s h e was r a n d o m i z e d to treat-
the SCL-90 and SAD). m e n t , d i d n o t d r o p o u t at any p o i n t i n t h e
c Two CT clients did not return their 3-month follow-up assessment packets (which included study, was n o t clinically d e p r e s s e d at t h e e n d
the SCL-90 and SAD). o f a c u t e t r e a t m e n t ( H R S D < 13), a n d re-
~Five FECT clients did not return their 3-month follow-up assessment packets (which included
mained depression-free throughout the
the SCL-90 and SAD), and one client did not return the SCL-90 with the follow-up assessment
packet. follow-up p e r i o d (did n o t m e e t criteria for
d e p r e s s i o n f o r 2 w e e k s a c c o r d i n g to t h e LIFE
i n t e r v i e w ) . T h i s i n d e x is a n i m p r o v e m e n t
h a d m o r e r e s p o n d e r s t h a n d i d CT o n all m e a s u r e s . Aver- o v e r s i m p l e r e l a p s e r a t e s f o r two r e a s o n s . First, it i n c l u d e s
a g i n g t h e BDI a n d H R S D , 79% o f F E C T c l i e n t s a n d 60% all clients r a n d o m i z e d to t r e a t m e n t a n d t h u s is a n i n t e n t -
o f C T c l i e n t s r e s p o n d e d to t r e a t m e n t . We d e f i n e d fail- t o - t r e a t analysis, w h i c h is m o r e inclusive a n d p o w e r f u l .

90 50
[] CT

~ 6o
= 30

8 20
U 50 n


30 -- -
Outcome measure Outcome measure

Figure 2. Percent of CT and FECT responders on major o u t c o m e Figure 3. Percent of CT and FECT failures on major o u t c o m e
variables. BDI = Beck Depression Inventory; HRSD = 17-item variables. BDI = Beck Depression Inventory; HRSD = 17-item
H a m i l t o n Rating Scale for D e p r e s s i o n ; SCL-90T = S y m p t o m Hamilton Rating Scale for Depression; SCL-90T = S y m p t o m
Check-List, 90 Item Version, total score; GAF = Global Assess- Check-List, 90 Item Version, total score; GAF = Global Assess-
ment o f Functioning. ment of Functioning.
Enhancing Cognitive Therapy 221

Endicott, Spitzer, Fleiss, & Cohen, 1976); (c) the Beck De- ested in evaluating the effect of the FECT e n h a n c e m e n t
pression Inventory (BDI; A. T. Beck et al., 1961); a n d (d) to the CT rationale. Second, we assessed additional rela-
the Symptom Checklist-90 Total Score (SCL-90; Deroga- tionship improvements using information gleaned from
tis, Lipman, & Covey, 1973). These four measures are es- the diagnostic interviews before the study started a n d at
tablished instruments for the m e a s u r e m e n t of depressive 3-month follow-up. Third, we assessed statements made
symptoms (BDI a n d HRSD), overall symptoms (SCL-90 by clients themselves d u r i n g the final therapy session
T), a n d general level of f u n c t i o n i n g (GAF). All measures using a new scale, created through a c o n t e n t analysis pro-
were administered at pretreatment, posttreatment, a n d at cedure, to assess for patterns of improvements from the
a 3-month fbllow-up. The HRSD a n d GAF were com- clients' perspectives. Finally, in order to measure thera-
pleted by a trained evaluator at p r e t r e a t m e n t a n d follow- pist a d h e r e n c e and competence, we created a n d adminis-
up a n d by the therapist d u r i n g the final session. Also, to tered a measure to check that the therapists were able to
assess diagnostic status a n d relapse rates at the 3-month i m p l e m e n t FECT a n d that FECT as i m p l e m e n t e d dif-
follow-up, we a d m i n i s t e r e d the L o n g i t u d i n a l Interval fered from standard CT. We assessed CT competency
Follow-up Evaluation (LIFE; Keller et al., 1987), a semi- using the Cognitive Therapy Scale (CTS; Dobson et al.,
structured retrospective interwiew that assesses the longi- 1985; Vallis et al., 1986). Each of these projects will be de-
tudinal course of depression a n d other disorders. scribed more fully below.
Second, we were interested specifically in the effects of
the FECT enhancement-s that emphasize interpersonal
problems a n d improvements, so we included several mea-
sures of interpersonal functioning. We administered the Because this study was not a randomized clinical trial,
Social Support Q u e s t i o n n a i r e (SSQ; Sarason, Levine, it is n o t possible to u n a m b i g u o u s l y attribute outcome dif-
Basham, & Sarason, 1983), a well-validated measure that ferences to the t r e a t m e n t conditions. Thus, o u r conclu-
asks subjects to list up to n i n e individuals to whom sub- sions about outcome are preliminary in nature. Despite
jects feel they could turn for support in each of six differ- the n u m e r o u s analyses conducted, we elected to retain
ent situations a n d to rate their satisfaction with available an u n c o r r e c t e d p v a l u e of .05 a n d risk Type I errors be-
support for each situation on a 6-point Likert scale. The cause of the p r e l i m i n a r y a n d e x p l o r a t o r y n a t u r e of
m e a n n u m b e r of individuals a n d m e a n satisfaction rat- this study.
ings across the six situations are used as subscale scores.
We also administered the Social Avoidance and Distress Major Outcomes
Scale (SAD; Watson & Friend, 1969). Although the SAD Statistical significance. We first tested for statistical sig-
is widely used in t r e a t m e n t research on social phobia, we nificance of m e a n differences between t r e a t m e n t condi-
believe it has relevance to depression in general a n d to tions on the four major outcome measures using ANCOVA,
FECT treatment of depression in particular. This is be- with pretreatment scores on each measure entered as co-
cause a behavioral view of depression specifically empha- variates. Table 5 shows sample sizes, means a n d standard
sizes a lack or avoidance of social reinforcers (Boiling, deviations for CT a n d FECT on the four measures at pre-
Kohlenberg, & Parker, 2000; Lewinsohn, 1974), a n d over- treatment, posttreatment, a n d follow-up. Table 5 also
c o m i n g social avoidance is targeted in both FECT a n d shows the p value ( o n e - t a i l e d ) for each ANCOVA com-
Behavioral Activation treatments for depression. paring CT a n d FECT. Results favored FECT at all time
We also wanted a measure of relationship satisfaction points, with a significant difference f o u n d o n the GAF at
that tracked progress weekly t h r o u g h o u t therapy. Before follow-up, and trends f o u n d on the HRSD a n d SCL-90 at
b e g i n n i n g each therapy session, clients responded to two posttreatment.
questions (in a confidential, sealed questionnaire that Effect sizes. Because of small sample size, we were par-
the therapist did n o t see) a b o u t their interpersonal relat- ticularly interested in effect sizes as measured by d, a n d
ing d u r i n g the previous week. The first question was, used adjusted values as instructed by C o h e n (1988, p.
"Have your relationships b e e n different than usual?" Cli- 380). Across all measures (see Table 5), the m e a n post-
ents were asked to respond to this question on a 5-point treatment effect size was .40, a n d the m e a n follow-up ef-
scale (1 = much worse, 3 = no change, a n d 5 = much better). fect size was .34.
T h e second question was, "If your relationships are differ- Clinical significance. W e also split our clients into
ent this week, is this difference due to therapy?" Clients groups of "responders" a n d "failures." We defined re-
were asked to respond o n a 4-point scale (1 = due to other sponders as those with a clinically significant reduction in
factors, 4 = definitely due to therapy). depressive symptoms, defined as greater than or equal to
We also c o n d u c t e d several intensive videotape rating 50% reduction in overall symptom severity measured at
projects to assess additional client reactions a n d changes pretreatment. Figure 2 shows the percentage of respond-
not assessed by existing measures. First, we were inter- ers in CT a n d FECT for each outcome measure. FECT
Enhancing Cognitive Therapy 223

S e c o n d , it takes i n t o a c c o u n t b o t h those w h o did n o t re-

s p o n d to a c u t e t r e a t m e n t a n d those w h o r e l a p s e d after a A
r e s p o n s e ; thus it m o r e fully c a p t u r e s the r a n g e o f depres- CT
sion t r e a t m e n t o u t c o m e s possible. We f o u n d that 47.1% - - FECT "~
,,.. .I ~ ./.~ i'~
o f C T clients a n d 74.1% o f F E C T clients w e r e in SR at 03
e- / "---,,, J /~" \ / J
follow-up (X2 = 1.29, p = .068). T h i s i n d e x s u b s u m e s sim- v
ple relapse rat#s: O n e C T client a n d o n e F E C T client h a d

Interpersonal Functioning Outcomes

O n t h e SSO~ n o significant d i f f e r e n c e s b e t w e e n c o n d i -
tions w e r e f o u n d in t h e n u m b e r o f social s u p p o r t s clients ~ 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
identified, a l t h o u g h results f a v o r e d F E C T with small ef- 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 20

fect sizes at p o s t t r e a t m e n t (.29) a n d follow-up (.27). Session

However, significant d i f f e r e n c e s w e r e f o u n d in relation-
ship satisfaction with large effect sizes at p o s t t r e a t m e n t , 4
F ( 1 , 26) - 5.57, p = 0.03, E S = .91, a n d f o l l o w - u p , B
F(1, 28) = 7.45, p = 0.01, E S = .99 (see Table 6). C T cli- ~CT t\x
ents 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 satisfac- t
--FECT /,,. // \v/\\ /
tion at 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 = 0.00 --- 0.38) o r 033
follow-up ( - 0 . 0 3 + 0.22), while F E C T clients i m p r o v e d .m

47% at p o s t t r e a t m e n t a n d 39% by follow-up. D i f f e r e n c e s

in p e r c e n t c h a n g e scores b e t w e e n c o n d i t i o n s w e r e signif-
i c a n t ( p o s t t r e a t m e n t : t[27] = 1.69, p = .050; follow-up
j#\// ~ v
t[29] = 1.84, p = .038).
O n t h e SAD, n o significant d i f f e r e n c e s w e r e f o u n d in
social 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 at post-
f i J i i p i q i ~ ; n q
t r e a t m e n t o r at follow-up, b u t m o d e r a t e effect sizes w e r e
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
f o u n d at b o t h t i m e p o i n t s f a v o r i n g F E C T ( p o s t t r e a t m e n t
d = .38; follow-up d = .36 ). P e r c e n t c h a n g e scores indi-
c a t e d a w o r s e n i n g o f social anxiety o v e r t h e c o u r s e o f Figure 4. Mean self-reported relationship improvements and
t h e r a p y f o r CT, while t h e F E C T a v e r a g e i n d i c a t e d an im- attributions for change over the course of therapy. (A) Mean rat-
p r o v e m e n t (CT = - 0 . 2 9 + 1.08; F E C T = 0.36 --- 0.43; ings on question: Have your relationships been different than
usual? 1 = m u c h worse, 3 = n o change, and 5 = m u c h better.
t[27] = 2.27, p = .016). Similar d i f f e r e n c e s w e r e f o u n d at
(B) Mean ratings on question: If your relationships are different
follow-up (CT = 0.09 _+ 0.63; F E C T = 0.39 + 0.43; this week, is this difference due to therapy? 1 = due to o t h e r
t[29] = 1.59, p = .062). factors, and 4 = definitely due to therapy.
C o n c e r n i n g weekly r e l a t i o n s h i p satisfaction, as s h o w n
in F i g u r e 4(a), b o t h C T a n d F E C T clients consistently re-
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 as t h e r 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 at all b u t t h r e e t i m e
p r o g r e s s e d . As s h o w n in F i g u r e 4(b), b o t h g r o u p s attrib- points.
u t e d this i m p r o v e m e n t increasingly to therapy, with F E C T Interpersonal f u n c t i o n i n g a n d treatment failures. We also
l o o k e d specifically at h o w the t r e a t m e n t failures (those
with less t h a n 25% c h a n g e o n the BDI) d i d o n these m e a -
sures. Since F E C T f o c u s e d o n b u i l d i n g i n t e r p e r s o n a l re-
Table 6
SSQ Relationship Satisfaction Subscale Scores by Condition, lating skills (in a d d i t i o n to u s i n g C T i n t e r v e n t i o n s ) , it was
p Values, and Effect Sizes possible t h a t t h e r e m i g h t h a v e b e e n i m p r o v e m e n t s in re-
lationships t h a t p r e c e d e d c h a n g e s in d e p r e s s i o n scores.
CT FECT T h e s e p a t i e n t s w o u l d have b e e n classified as failures o n
Time N M +- SD N M +- SD p ES t h e BDI b u t w o u l d d i f f e r f r o m C T f a i l u r e s in t h a t n e w
i n t e r p e r s o n a l r e l a t i n g skills w e r e l e a r n e d .
Pre 15 4.02 -+ 1.48 23 4.04 +- 1.42 .97 O u r d a t a s u p p o r t e d this possibility. At posttest, t h e
Post 11 4.08 - 1.61 18 4.69 -+ 0.92 .01 .91
F E C T failure for w h o m we h a d d a t a ( o n e F E C T failure
Follow-up 13 4.05 -+ 1.66 18 4.76 _+ 1.24 .01 .99
a n d o n e C T failure d i d n o t r e t u r n t h e i r p o s t t r e a t m e n t as-
Note. p = p value for between-conditions ANCOVA, ES = Effect size. sessments) d i d n o t fail o n t h e S S Q o r SAD, b u t t h e C T
224 Kohlenberg et al.

failures did. O n the SSQ, the CT failures' percent change consistently report improved relationships, n o r did they
scores (pre to post) averaged .08 with only one above .00, attribute any improvements that did occur to therapy.
while the FECT failure's p e r c e n t change score was 1.00. Given the very small n u m b e r of treatment failures, these
O n the SAD, the CT failures' percent change scores (pre results are merely suggestive a n d should be i n t e r p r e t e d
to post) averaged - . 4 4 with n o n e above .04, while the with caution.
FECT failure's percent change score was .40. The same
was f o u n d at follow-up (all seven failures r e t u r n e d their Reaction to Rationale
follow-up assessments). O n the SSQ, the CT failures' per- O n e of the two major e n h a n c e m e n t s to CT in FECT is
cent change scores averaged - . 1 0 , while the FECT fail- an e x p a n d e d rationale. At the e n d of Session 1, therapists
ure's percent change scores averaged .29. O n the SAD, the were e n c o u r a g e d to distribute the appropriate brochures
CT failures' percent change scores averaged - . 0 7 , while (Beck a n d Greenberg's 1995 Coping With Depression for
the FECT failure's percent change scores averaged .29. the CT condition a n d Coping With Depression a n d a FECT
FECT failures also consistently reported that their re- b r o c h u r e for the FFCT condition), a n d to discuss them
lationships were d o i n g better as therapy progressed (Fig- with the client in Session 2. O u r hypothesis was that the
ure 5a), a n d they a t t r i b u t e d this i m p r o v e m e n t in- e x p a n d e d FECT rationale would improve the match be-
creasingly to therapy (Figure 5b). CT failures did not tween client a n d therapy a n d clients would r e s p o n d more
favorably to the e x p a n d e d rationale than to the standard
CT rationale.
A / I O u r Reaction to Rationale scale (RTR) was modified
~CT / I 4
from Addis's Reaction to Rationale Scale (unpublished)
-- - F E C T ,' ', /
-~ / i / ~ t a n d consists of 7 items scored o n a 5-point scale of - 2
I I I / I l (strongly negative) to + 2 (strongly positive). Two items on
e.-- ' /--'~ I 'l / -J t A .,l that scale allowed for comparisons between the FECT
/ ~ I ./ ~/ ~ I',k
~3 a n d CT conditions: overall response to the rationale a n d
response to the cognitive conceptualization. Two re-
search assistants assessed clients' reactions to rationales
by rating clients' responses in Session 2 using the RTR. It
was impossible to m a i n t a i n blindness to t r e a t m e n t condi-
tion because the rationales identify the condition. We in-
; , i,,, i i i i , i i i i i i : ;,, ~, i I , , : ! cluded treatment completers (CT = 15, FFCT = 23) a n d
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
dropouts who completed Session 2 (CT = 1, FECT = 3)
Session in this analysis. In four cases (3 CT, 1 FECT) there was n o
discussion of the rationale in Session 2, leaving 13 CT cli-
ents a n d 25 FECT clients. Looking at overall response to
B i~ /
~CT / ~ / the respective rationales, FECT clients displayed a signif-
--FECT h / ~ / icantly more positive overall response than did CT cli-
I \ I ~ I
I \ d ~ I ents: CT M = .15, SD = .80; FECT M = .88, SD = .73;
~3 F'", I t(36) = 2.83, p < .01. Also, clients displayed a signifi-
cantly more positive reaction to the CT conceptualization
t-- / - - "k\ / A
in FECT when it was presented as part of the e x p a n d e d
/ ,/A / \ rationale than did clients in CT when it was presented in
isolation: CT M = .08, SD = .64; FECT M = .83, SD = .65;
t(33) = 3.41, p < .01. (Two additional FECT clients dis-
played n o specific reaction to the CT conceptualization
a n d were n o t i n c l u d e d in this analysis.)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Relationship Improvements From the SCID to the LIFE
Figure 5. Treatment failures' (CT = 5, FECT = 2) m e a n self- D u r i n g the SCID interview at p r e t r e a t m e n t a n d the
reported relationship i m p r o v e m e n t s and attributions for change LIFE interview at follow-up, the interviewer took notes
o v e r the course o f therapy. (A) M e a n ratings on question: Have about all aspects of clients' lives. To create an additional
y o u r relationships been different than usual? ! = m u c h worse,
measure of changes in interpersonal f i m c t i o n i n g from
3 = no change, and 5 = m u c h better. (B) M e a n ratings on ques-
p r e t r e a t l n e n t to follow-up, we isolated the notes a b o u t cli-
tion: If y o u r relationships are different this w e e k , is this differ-
ence due t o t h e r a p y ? ! = d u e to o t h e r factors, and 4 = defi- ents' relationships, a n d had two advanced u n d e r g r a d u a t e
nitely due to therapy. research assistants rate the degree of i m p r o v e m e n t from
Enhancing Cognitive Therapy 225

the SCID to the LIFE. Raters were b l i n d to t r e a t m e n t con- Adherence and Competence Measurement and Results
dition a n d to o t h e r client outcomes. A 7-point scale with A d h e r e n c e m e a s u r e m e n t is a central feature of treat-
verbal anchors (ranging from 1 = much worse, 4 = no m e n t d e v e l o p m e n t . F o r FECT, t h e r e were two basic ques-
change in relationships, to 7 = much improved) was used. To tions to answer. First, d i d o u r therapists d o FECT? Sec-
evaluate i n t e r r a t e r reliability, each rater i n d e p e n d e n t l y ond, is FECT truly different from s t a n d a r d CT? We
scored three clients that the o t h e r rater h a d i n d e p e n - d e v e l o p e d the T h e r a p i s t In Session Strategies Scale
dently scored, with 100% a g r e e m e n t . (THISS) a d h e r e n c e measure to answer these questions.
Because the range o f scores was restricted (no client T h e m e t h o d a n d structure o f the THISS was a d a p t e d
was r a t e d as 1, 2, o r 7, a n d only 1 client was rated 3), rat- from the Collaborative Study Psychotherapy Rating
ings were t h e n categorized as either "improved" (scores Scale-Version 6 (CSPRS-6; H o l l o n et al., 1987), a n d the
o f 5 o r 6) or "no c h a n g e or n o t improved" (scores o f 3 o r Vanderbilt T h e r a p i s t Strategy Scale (VTSS; Butler, Henry,
4). Results indicate that relationships i m p r o v e d signifi- & Strupp, 1992). T h e 36 THISS items were divided into
cantly m o r e frequently for FECT (85%, 17/20) clients four rational c o n t e n t subscales: CT, In Vivo CT, FAP, a n d
than for CT (53%, 8 / 1 5 ) clients, X2 = 4.21, p = .047. I n t e r p e r s o n a l T h e r a p y (IPT). For the In Vivo CT sub-
scale, items were m o d i f i e d to specify a focus o n in vivo
Clients' Statements of Improvement material. For example, item 60 from the CSPRS-6,
We also assessed clients' statements o f i m p r o v e m e n t
E x p l o r i n g underlying assumptions: Therapist ex-
d u r i n g the 20th session o f treatment. O u r hypothesis was
plores with the client a g e n e r a l belief that u n d e r l i e s
that clients' statements o f i m p r o v e m e n t would favor
many o f the client's specific automatic negative
FECT and reflect the increased focus on the client-therapist
relationship in FECT. A c o n t e n t analysis o f Session 20 di-
alogue yielded 27 exhaustive a n d mutually exclusive cate- was m o d i f i e d into two separate items:
gories. For example, o n e category was " b e c o m i n g aware E x p l o r i n g daily life assumptions: T h e r a p i s t ex-
o f feelings," d e f i n e d as a r e p o r t that expressing o r being plores with the client a g e n e r a l belief that underlies
aware o f their feelings has b e e n useful o r helpful to the many of the client's specific automatic negative
client in some way. Two categories dealt with cognitive thoughts in daily life.
change, for example, "cognitive strategies," defined as a
E x p l o r i n g in-vivo u n d e r l y i n g assumptions: Thera-
r e p o r t that the client b a d b e e n h e l p e d by using a cogni-
pist explores with the client a g e n e r a l belief that
tive strategy (such as using t h o u g h t logs or thinking up al-
u n d e r l i e s many of the client's specific in-session
ternative ways to view a situation). Two categories dealt
automatic negative thoughts.
specifically with relationships, for example, "attitude a n d
behavior toward others," d e f i n e d as a r e p o r t o f a positive T h e FAP subscale i n c l u d e d 6 items m e a s u r i n g general
change in the client's attitude o r behavior with respect to in vivo interventions specific to FAP, such as c o m m e n t i n g
o t h e r people. For 19 o f the 27 categories, raters also were on some aspect o f the client's in vivo behavior, disclosing
asked to distinguish w h e t h e r the particular i m p r o v e m e n t his or h e r own thoughts o r feelings a b o u t the client's in
was attributed specifically to the therapist (e.g., "You vivo behavior, a n d providing an e x p a n d e d rationale for
showed m e . . . " ) or n o t (e.g., "I f o u n d o u t . . . " ) . Two un- t r e a t m e n t that allows for additional reasons for depres-
dergraduate research assistants, blind to condition, rated sion o t h e r than the client's cognitions. T h e FAP subscale
the tapes. Twenty-five p e r c e n t o f the tapes were rated by was distinguished from the In Vivo CT subscale because
the graduate research assistants who developed the mea- no FAP subscale items m e a s u r e d cognitive therapy
sure as criterion ratings for a reliability check on the raters. interventions.
Results i n d i c a t e d that subjects in the FECT c o n d i t i o n R a t i n g procedures. Sessions 4, 8, 12, a n d 16 were r a t e d
identified m o r e i m p r o v e m e n t s overall ( m e a n n u m b e r o f by trained u n d e r g r a d u a t e s for the 38 clients who com-
statement categories identified): CT = 4.47, SD = 2.36, p l e t e d the study. Raters h a d to m e e t a reliability criterion
FECT = 8.04, SD = 3.27, t(36) = 3.66, p < .01. Further- of at least .7 for three consecutive ratings c o m p a r e d to
more, subjects in the FECT c o n d i t i o n attributed improve- data raters before b e i n g used as data raters (calculated
ments m o r e often to the therapist: CT M = 0.53, SD = using the intraclass correlation coefficient for generaliz-
0.74, FECT M = 3.26, SD = 1.94, t(equal variances n o t as- ing to o t h e r trained raters; ICC[2,k]) (Armstrong, 1981;
sumed, 30) = 6.10, p < .01. In addition, there were no Shrout & Fleiss, 1979). Reliability o f data raters com-
significant differences between FECT a n d CT subjects in p a r e d to the e x p e r t criterion ratings was f o u n d to be high
the identification o f cognitive strategies as helpful, b u t ( m e a n ICC = .88, range = .75 to .96). T h e internal con-
FECT subjects also specified m o r e relationship improve- sistency o f the scale was c~ = .64 with subscale values o f
ments, CT M = 0.73, SD = 0.70, FECT M = 1.17, SD -= .79, .74, .58, and .60, respectively, for FAP, In Vivo CT, CT,
0.78, t(36) = 1.77, p = .04. a n d IPT.
Z:Z6 Kohlenberg et al.

Summary of adherence and competence. THISS ratings

.... FAP
CT Waves
showed that FAP subscale scores were elevated d u r i n g
FEC T Waves
CT-IV FECT. Interestingly, in vivo CT i n t e r v e n t i o n s were infre-
~2.5 -- -- CT-DL q u e n t overall, a l t h o u g h m o r e likely to occur d u r i n g
o A i FECT by wave 10. CT subscale scores were similar in
\ both t r e a t m e n t conditions. These data indicate that the
42 f
\: /
standard CT d o n e by o u r therapists in the initial phase
\ I ~ / "" of o u r project employed n o focus o n the in vivo aspect of
¢- !~ / ""
therapy. Further, these same therapists did use in vivo
~1.5 strategies d u r i n g FECT. In addition, c o m p e t e n c y ratings
suggest that therapists were p e r f o r m i n g c o m p e t e n t CT
t h r o u g h o u t the study, which was expected given their
collective experience a n d training. These results, how-
1 2 3 4 5 6 7 8 9 10
ever, must be i n t e r p r e t e d with caution. Although the
particular cognitive therapists in o u r study did not use in
Figure 6. Mean THISS subscale scores by wave. Waves 1-4 are vivo strategies d u r i n g CT, other cognitive therapists
CT waves, 5 - 1 0 are FECTwaves. FAP = FAP subscale; CT-tV =
might. Further, given o u r A-B design, there are n u m e r -
In Vivo CT subscale; CT-DL = Daily life CT subscale.
ous other variables that could have c o n t r i b u t e d to these
findings. For example, because the CT clients were seen
Results. Four mixed b e t w e e n / w i t h i n subjects ANOVAs first, it is possible the therapists were simply a d a p t i n g to
were c o m p u t e d with each subscale score as the depen- o u r study procedures a n d that the increase in in-vivo
d e n t measure, condition as a between-subjects factor, a n d work d u r i n g FECT simply reflects h a b i t u a t i o n or a n
session as a within-subjects factor. Only FAP subscale acclimatization effect.
scores were significantly different between conditions,
F(1, 36) = 19.15, p < .01, with significantly higher scores Relationship Between Adherence and Outcome
in the FECT condition (M = 1.57, SD = .35) than in the To assess the relationship between THISS subscale
CT condition (M = 1.15, SD = .16). scores a n d outcome, five regression equations were eval-
O u r a d h e r e n c e data also is informative regarding uated, each with BDI posttest scores as the d e p e n d e n t
therapist training issues. Figure 6 presents THISS sub- variable. Two-tailed significance tests were used because
scale scores for each wave of the study (IPT subscale specific predictions were n o t made a b o u t each subscale.
scores are n o t shown because n o differences were f o u n d First, BDI pretest scores were e n t e r e d o n the first step,
a n d n o training issues are relevant to it). As can be seen, a n d all four THISS subscales were e n t e r e d simuha-
In Vivo CT subscale scores were low t h r o u g h o u t the neously on the second step. This equation showed that
study, although d u r i n g the final wave therapists were able BDI pretest scores accounted for 10% of the variance a n d
to incorporate in vivo CT into therapy. FAP subscale the subscales accounted for an additional 14%. T h e n ,
scores show a marked increase at the wave-5 transition four additional equations were evaluated to estimate the
from CT to FECT, r e m a i n elevated t h r o u g h o u t the FECT u n i q u e c o n t r i b u t i o n of each subscale score, after ac-
waves, a n d show a second j u m p d u r i n g the final wave. CT c o u n t i n g for the c o n t r i b u t i o n of BDI pretest scores a n d
subscale scores show a marked drop at the wave-5 transi- other subscale scores (Shaw et al., 1999). Each regression
tion from CT to FECT as therapists focused on imple- equation added BDI pretest scores o n the first step, three
m e n t i n g unfamiliar techniques, b u t CT scores regain of the four THISS subscale scores o n the second step,
their former elevations by waves 9 a n d 10. a n d the r e m a i n i n g THISS subscale score on the last step.
CT competency. Fifty-two (24 CT a n d 28 FECT) tapes Table 7 shows the results of these four regression equa-
were rated for CT competency by Dr. Keith Dobson using tions: the p e r c e n t of u n i q u e variance explained by each
the Cognitive Therapy Scale (CTS). Sessions 4 a n d 12 subscale when added last (R 2 change), the/=test evaluat-
were targeted for rating, and 30 of the 38 clients had at ing whether the u n i q u e variance explained by that sub-
least one session rated. There were n o significant differ- scale is a significant change from that explained by the
ences in CTS total scores between therapists or between other subscales, a n d the p value for that test. Table 7
conditions, n o r was there a significant Therapist × Condi- shows that the In Vivo subscale u n i q u e l y accounted for
tion interaction. T h e m e a n CTS total score was 43.58, most of the variance explained by the subscales (R 9
SD = 6.00, which is considered adequate a n d comparable change = .10), a n d the other subscales had negligible
to other studies. For comparison, Shaw (1984) proposed a contributions. The In Vivo subscale's u n i q u e contribu-
competency cutoff score of 39, and the m e a n CTS total tion was significant, F f o r R 2 change (1, 32) = 4.26, p =
score of CT therapists in the TDCRP was 41.28, SD = 4.24. .047, and no other subscales were significant contributors.
Enhancing Cognitive Therapy 227

Table 7 involved different skills. It is also of interest that even low

Results of Regression Equations With THISS Subscales as levels o f in vivo CT led to i m p r o v e d outcomes. Future
Predictors and BDI and SAD Posttest Scores work will focus on i m p r o v i n g m e t h o d s for training thera-
as Dependent Variables pists in In Vivo CT. T h e work of Safran a n d Segal (1990)
Measure and R2 Ffor R2 may be useful in this regard.
Subscale Change Change p Value Keeping in m i n d that this was an u n c o n t r o l l e d trial
a n d findings must be c o n s i d e r e d p r e l i m i n a r y in nature,
the o u t c o m e data are promising. FECT achieved moder-
In vivo .10 4.26 .05
FAP .00 0.14 .71 ate effect sizes over CT on o u t c o m e measures tradition-
CT .01 0.47 .50 ally used in depression studies. FECT e v i d e n c e d incre-
IPT .00 0.00 .99 mental efficacy, even t h o u g h CT p e r f o r m e d well in this
SAD study (60% o f CT clients r e s p o n d e d successfully). Fur-
In vivo .09 5.38 .03 ther, clients' self-reported statements of i m p r o v e m e n t
FAP .02 1.28 .27 suggested that FECT clients felt they h a d i m p r o v e d m o r e
CT .00 0.10 .76
than d i d CT clients, a n d specifically a t t r i b u t e d this im-
IPT .03 2.00 .17
p r o v e m e n t to the therapy.
Note. BDI = Beck Depression Inventory; SAD = Social Avoidance FECT i m p r o v e d i n t e r p e r s o n a l functioning. O n o u r
and Distress Scale; R2 change = the percent of unique variance measure of i n t e r p e r s o n a l satisfaction, CT clients d i d n o t
explained by each subscale when added last; F for R2 change = F
improve at all, while FECT clients i m p r o v e d significantly.
test evaluating whether the unique variance explained by that sub-
scale is a significant change from that explained by the other Further, an e x a m i n a t i o n of clients classified as failures ac-
subscales. c o r d i n g to the BDI showed that those who received FECT
i m p r o v e d on measures o f i n t e r p e r s o n a l f u n c t i o n i n g
while CT failures d i d not. O n e i n t e r p r e t a t i o n o f this find-
(Note that this result is statistically e q u i v a l e n t to find- ing is that the items on the BDI m i g h t n o t reflect the im-
ing a significant [3 only for the In Vivo subscale in the p r o v e m e n t o f a client who is c o n f r o n t i n g his o r h e r inter-
first e q u a t i o n , w h e n all f o u r subscales were e n t e r e d personal avoidance a n d taking risks because these involve
simultaneously.) an increase in psychological distress. However, confront-
To assess the relationship between THISS subscale ing avoidance increases the probability o f achieving m o r e
scores a n d i n t e r p e r s o n a l outcomes, a similar set o f equa- intimate a n d satisfying relationships a n d it is possible that
tions were evaluated using SAD pre- a n d p o s t t r e a t m e n t the FECT failures would b e c o m e less depressed over
scores instead o f BDI scores, with similar results. SAD pre- time. Consistent with this i n t e r p r e t a t i o n , the generally
test scores a c c o u n t e d for 50% o f the variance, a n d the improved interpersonal functioning of FECT clients might
subscales a c c o u n t e d for an additional 11%. Table 7 shows increase their resistance to relapse. Research involving
that the In Vivo subscale uniquely a c c o u n t e d for most o f longer-term follow-up is b e i n g p l a n n e d to provide d a t a
this additional variance (R 2 c h a n g e = .09) a n d the o t h e r on these issues.
subscales h a d negligible contributions. T h e In Vivo sub- FECT clients also r e s p o n d e d m o r e favorably to their
scale's u n i q u e c o n t r i b u t i o n was significant, F for R 2 rationale than did CT clients. This was p r e d i c t e d given
change (1, 23) = 5.38, p = .03, a n d no o t h e r subscales that FECT's e x p a n d e d rationale was i n t e n d e d to improve
were significant contributors. therapy-client matching.
Future studies will provide stronger tests o f FECT's ef-
ficacy c o m p a r e d to CT on diverse o u t c o m e measures,
C u r r e n t results are promising, a n d a d d to a growing b o d y
Summaly and C o n c l u s i o n
o f literature on new, behaviorally i n f o r m e d t r e a t m e n t ap-
CT therapists trained in FECT increased their focus p r o a c h e s for adult o u t p a t i e n t psychotherapy (Nelson-
on using the client-therapist relationship as an in vivo Gray, Gaynor, & Korotitsch, 1997) such as FAP (R. J.
l e a r n i n g opportunity. T h e in vivo work mostly targeted K o h l e n b e r g & Tsai, 1991), Acceptance a n d C o m m i t m e n t
intimacy, avoidance, a n d o t h e r i n t e r p e r s o n a l relating T h e r a p y (Hayes et al., 1999), a n d Dialectical Behavior
skills. A l t h o u g h o u r therapists markedly increased their T h e r a p y (Linehan, 1993). These treatments may h o l d
focus on client-therapist intimate a n d avoidant relating p r o m i s e in that they are r o o t e d in behavioral principles,
when d o i n g FECT, they showed relatively small increases but, unlike earlier behavioral forays into a d u l t o u t p a t i e n t
in in-vivo cognitive therapy. This was surprising since, as psychotherapy, they d o n o t discard cognitive p h e n o m -
e x p e r i e n c e d cognitive therapists, they were already profi- ena; they foster deep, intense psychotherapy e x p e r i e n c e s
cient at d o i n g CT interventions, whereas a t t e n d i n g to the a n d genuine, curative client-therapist relationships often
client-therapist intimacy a n d i n t e r p e r s o n a l avoidance associated with n o n b e h a v i o r a l approaches.
228 Kohlenberg et al.

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Watson, D., & Friend, R. (1969). Measurement of sociabevaluative anx- Address correspondence to RobertJ. Kohlenberg, Department of
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1635; e-mail:
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This work was supported in part by the National Institute of Mental

Health Grant MH-53933. We also wish to acknowledge Reo Wexner for Received: January 6, 2000
her contributions to this project. Accepted: April 1, 2000

t • •