Early Behavioral, Not Cognitive, Gains Predict Treatment Outcome

Two elements of cognitive therapy (CT) that have been shown to influence overall treatment outcome are therapeutic alliance and treatment adherence. When clients are also using antidepressant medication (ADM) in conjunction with therapy, these elements can dramatically increase positive outcome and reduce symptom severity. The early stages of therapy, specifically, the first few sessions, are critical to recovery, and change that occurs during these first sessions can be indicative of overall prognosis. Therefore, to further examine how alliance and adherence predict change, Daniel R. Strunk of the Department of Psychology at Ohio State University conducted a study that looked at how each of these variables affected symptom severity in a sample of 176 individuals with depression.

All of the participants were taking ADMs and were assessed after the first and third session of CT. Strunk found that the most significant indicator of change was the behavioral aspect of CT, although alliance did account for some change in the early sessions. The results showed that the participants were able to realize dramatic changes in depressive symptom severity when they adhered to the behavioral homework tasks instructed by the therapists. When Strunk compared these results to those of participants with varying ADM protocols, he found that again, the behavioral element of the CT was the strongest indicator of change in early sessions.

Strunk believes the findings of his study are important because they demonstrate the impact that the behavioral component of therapy has on symptom trajectory. Although therapeutic alliance is an important aspect of positive therapy and forms the foundation of future disclosure and transformation, focusing on behavioral trends appears to have a more immediate effect on negative symptoms. Strunk hopes that future endeavors in this area will yield similar results and if they do, would have profound clinical implications. He added, “Our results would suggest that behavioral methods/homework are uniquely important in combined treatment, while the positive effects of cognitive methods are less robust or negligible in this context.”

Strunk, D. R., Cooper, A. A., Ryan, E. T., DeRubeis, R. J., Hollon, S. D. (2012). The process of change in cognitive therapy for depression when combined with antidepressant medication: Predictors of early intersession symptom gains. Journal of Consulting and Clinical Psychology. Advance online publication. doi: 10.1037/a0029281

Related articles:
What is CBT?
One Size Doesn’t Fit All When It Comes to Treatment

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  • andrea


    July 20th, 2012 at 4:13 AM

    The patient/therapist relationship is critical to recovery, and just how soon the two are able to form a trusting relationship, that looks like is even more key to the long term recovery of a patient.

  • Jacqui


    July 20th, 2012 at 11:24 AM

    A good therapist is someone who will listen to her patient’s needs and come up very quickly with a plan for helping you to revise your life. She could give you some fairly simple tasks for helping you change your behavior, and as long as you give them some practice at home I think that you will see results in your life much better and sooner than you may have anticipated. And this is ultimately what will keep people motivated and driven to continue their treatment. They want to be able to see some early success, see that they are making a dent in some of this chaos that is currently their lives and start moving forward. It is great to get in depth with your issues, and perhaps you will decide to do that as your treatment progresses. But for me I want to see some immediate improvements, and being with a good therapist whom you can trust is essentially going to give you some tools that will help you begin revising your life in a good way today.

  • annabeth


    July 20th, 2012 at 9:02 PM

    its just so important for the therapists to be on their toes in the first few sessions because it usually makes or breaks the treatment.and from the client’s point of view,finding a therapist who is ready to listen and also someone who makes you feel comfortable and easy to work with are some of the desired qualities.

  • Hannah


    July 21st, 2012 at 4:53 AM

    But I would point out that in order for a client to feel like they even want to adhere to the behavioral changes set forth by the therapist, they have to have a bond with the therapist established first.

  • ellis


    July 23rd, 2012 at 4:27 PM

    Many therapists will spend a great deal of time trying to establish a solid working relationship with a client, which is something that has to be done. So isn’t this putting a whole lot of pressure on them to also be expected to develop this relationship as well as make almost instantaneous progress? To me it seems like it would be far more iomportant to encourage a trusting relationship with the client first; otherwise how will they ever feel comfortable sharing things with you and becoming a willing participant in their own treatment?

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