Prevention & Treatment, Volume 3, Article 23, posted June 2, 2000

Reprinted from Journal of Consulting and Clinical Psychology, Volume 64, No. 2, 295–304
Copyright 1996, 2000 by the American Psychological Association

A Component Analysis of Cognitive–

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Behavioral Treatment for Depression

Neil S. Jacobson
University of Washington

Keith S. Dobson
University of Calgary

Paula A. Truax, Michael E. Addis, Kelly Koerner,

Jackie K. Gollan, Eric Gortner, and Stacey E. Prince
University of Washington

ABSTRACT
The purpose of this study was to provide an experimental test of the theory of
change put forth by A. T. Beck, A. J. Rush, B. F. Shaw, and G. Emery (1979) to
explain the efficacy of cognitive—behavioral therapy (CT) for depression. The
comparison involved randomly assigning 150 outpatients with major depression
to a treatment focused exclusively on the behavioral activation (BA) component
of CT, a treatment that included both BA and the teaching of skills to modify
automatic thoughts (AT), but excluding the components of CT focused on core
schema, or the full CT treatment. Four experienced cognitive therapists
conducted all treatments. Despite excellent adherence to treatment protocols by
the therapists, a clear bias favoring CT, and the competent performance of CT,
there was no evidence that the complete treatment produced better outcomes, at
either the termination of acute treatment or the 6-month follow-up, than either
component treatment. Furthermore, both BA and AT treatments were just as
effective as CT at altering negative thinking as well as dysfunctional
attributional styles. Finally, attributional style was highly predictive of both
short- and long-term outcomes in the BA condition, but not in the CT condition.

Preparation of this article was supported by Grants 2R01 MH44063-06 and 5K02 MH00868-
05 from the National Institute of Mental Health.
Received: January 5, 1995

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 Revised: February 25, 1995
Accepted: March 1, 1995

The cognitive model of depression ( Beck, Rush, Shaw, & Emery, 1979 ) states that
depressed individuals have stable cognitive schemas (also referred to as underlying
assumptions or core beliefs) that develop as a consequence of early learning. These schemas
predispose people toward negative interpretations of life events (i.e., cognitive distortions or
automatic thoughts [ATs]), which in turn, lead the depressed person to engage in depressive
behavior. Cognitive—behavioral therapy (CT) for depression includes interventions that
focus on publicly observable behavior, dysfunctional ATs, and inferred underlying cognitive
structures or schemas. The treatment is conducted in a progressive manner so that the
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therapist first focuses on overt behavior change; teaches the client to assess and, when
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necessary, correct situation-specific distortions in thinking; and finally moves to the

identification and modification of more stable depressive schemas and presumed cognitive
structures.

A number of investigators have documented the clinical usefulness of CT for depression. In a

meta-analysis of this approach, Dobson (1989) suggested that CT is at least as powerful and
perhaps more effective than behavior therapy, pharmacotherapy, and other psychotherapies
or waiting-list control conditions. Some have questioned the state of this evidence ( Hollon,
Shelton, & Loosen, 1991 ), in part based on the results of the Treatment of Depression
Collaborative Research Program (TDCRP; Elkin et al., 1989 ). However, even in the
TDCRP, CT showed long-term effects that were at least as durable, if not more durable, than
pharmacotherapy or interpersonal psychotherapy ( Shea et al., 1992 ).

Beck and his associates are quite specific about the hypothesized active ingredients of CT,
stating throughout their treatment manual ( Beck et al., 1979 ) that interventions aimed at
cognitive structures or core schema are the active change mechanisms. Despite this
conceptual clarity, the treatment is so multifaceted that a number of alternative accounts for
its efficacy are possible. We label two primary competing hypotheses the "activation
hypothesis" and the "coping skills" hypothesis.

According to the activation hypothesis, CT effects change through the activation of clients;
that is, by instigating them to become active again and to put themselves in contact with
available sources of reinforcement. Instigative interventions play a major role particularly in
the early stages of CT and may be largely responsible for its effectiveness. It has been noted
that much of the change during CT occurs within the first few weeks ( Rush, Beck, Kovacs,
& Hollon, 1977 ), when instigations toward activation play a prominent role in the treatment.
Previous studies that found CT more effective than behavioral activation ([BA] e.g., Shaw,
1977 ) may not have used activation strategies that work as well as those used in CT. If an
entire treatment based on activation interventions proved to be as effective as CT, the
cognitive model of change in CT (stipulating the necessary interventions for the efficacy of
CT) would be called into question. Moreover, in addition to these important theoretical
questions, there are important practical considerations: Are the elaborate cognitive
interventions directly designed to modify core schema necessary? It may be that a much
more parsimonious set of treatment procedures would have comparable effects.

A second hypothesis that could explain the efficacy of CT is the coping skills hypothesis.
According to this hypothesis, clients learn to cope with depressing events and depressogenic

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 thinking during CT, and it is this new set of skills that, along with activation, accounts for the
alleviation of depressive behavior. In other words, it is not that core cognitive structures are
altered, but that people learn effective coping strategies for dealing with life stress and the
ATs associated with these events. If structural changes in core schema are really necessary
for changes in clients' depression, then CT should be significantly more effective than a
treatment that stops with the training in modifying automatic dysfunctional thinking in
specific situations.

To test these competing hypotheses, we conducted an experiment comparing three treatments

for major depression in adults: one that included only behavioral activation (BA treatment),
another that included both BA and work on ATs (AT treatment), and a third that
corresponded to the full cognitive therapy of depression (CT treatment). The full CT
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treatment included not only work on BA and AT, but also a direct focus on identifying and
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modifying core depressogenic schema. According to the cognitive theory of depression, CT

should work significantly better than AT, which in turn, should work significantly better than
BA.

A second purpose of the present study was to examine the correlations between changes in
specific mechanisms and outcome, both within and across treatments. For example,
independently of whether BA worked as well as CT, was CT more successful at modifying
cognitive schema than BA? In other words, do the various treatments differentially effect the
processes that they are supposed to effect? A related question concerns whether the three
treatments operate by means of different mechanisms, independently of their overall efficacy.
For example, BA may work as well as CT but for different reasons. Do the variables that
correlate with a positive acute treatment response differ across the treatments? One may
expect BA to be more highly correlated with outcome in the BA condition than in the CT
condition. More generally, it would be of interest to know how treatments effect change,
independently of how well they work.

Method
Sample
The sample consisted of 152 1 participants who met criteria for major depression according
to the Diagnostic and Statistical Manual of Mental Disorders (3rd edition, revised; DSM—
III—R ; American Psychiatric Association, 1987 ), scored at least 20 on the Beck Depression
Inventory (BDI; Beck et al., 1979 ), and scored 14 or greater on the 17-item Hamilton Rating
Scale for Depression. (HRSD; Hamilton, 1967 ). DSM—III—R diagnoses were based on the
Structured Clinical Interview for DSM—III—R (SCID; Spitzer, Williams, & Gibbon, 1987 ).
Originally, training was provided by Michael First from the biometrics research department
at the New York State Psychiatric Institute, where the SCID was developed. Further training
and supervision was provided by Donna Miller, an experienced psychiatrist and expert SCID
interviewer who was on site. The interviews themselves were conducted by clinical
psychology graduate students, carefully trained and supervised by Miller. Raters were not
informed of treatment condition. Interrater reliability between Miller and SCID raters
was .90, on the basis of the percentage of times Miller and the rater agreed on the primary
diagnosis. Raters were also not informed of which tapes were being rated by Miller.

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 Similarly, the HRSD was administered as an adjunct to the SCID. For a previous study, our
research group had rewritten the HRSD so that it could be inserted into a structured
diagnostic interview ( Whisman et al., 1989 ). This version of the HRSD has excellent
psychometric properties and is highly reliable. Moreover, although it is a clinical interview, it
can be administered by technicians without loss of reliability. Raters were not informed of the
treatment condition of the participant or of which tapes were being assessed for reliability.

Eighty percent of the participants were referred directly from Group Health Cooperative, the
largest health maintenance organization (HMO) in the state of Washington. The remainder
were recruited from public service announcements. Of the original 152 participants accepted
into the study, 110 were women and 42 were men. One hundred thirty-seven of this group
completed therapy (defined as receiving at least 12 sessions of treatment). Thus, in all there
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were 15 dropouts (an 8% attrition rate): Three of these dropouts refused random assignment
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and never had a treatment session. The rates of attrition during acute treatment were
comparable in the three conditions.

Exclusion criteria included a number of concurrent psychiatric disorders (bipolar or psychotic

subtypes of depression, panic disorder, current alcohol or other substance abuse, past or
present schizophrenia or schizophreniform disorder, organic brain syndrome, and mental
retardation). We also excluded participants who were in some concurrent form of
psychotherapy, who were receiving psychotropic medication, or who needed to be
hospitalized because of imminent suicide potential or psychosis.

After qualifying for the study, participants were randomly assigned to one of the three
treatment conditions after matching to ensure group equivalence on the following variables:
number of previous episodes of depression, presence or absence of dysthymia, severity of
depression, gender, and marital status (married, divorced, single, or widowed).

Table 1 shows means and standard deviations for the demographic variables. We first
correlated these variables with primary measures of treatment outcome to determine whether
they should be used as covariates in the primary analyses. None of them (gender, years of
education, marital status, or percent Caucasian) were significantly correlated with either
posttreatment BDI and HRSD scores, or changes from pre- to posttreatment on these two
measures of depression severity. There were also no significant differences between
treatment conditions on any of these variables, nor did the treatments differ in their
pretreatment BDI scores. However, clients receiving CT and AT treatment had significantly
higher pretreatment HRSD scores than did those receiving BA treatment, F (2, 148) = 3.52, p
< .05.

Therapists
Four experienced cognitive therapists provided treatment in all three conditions. Their
average age was 43.5 years (range, 37 to 49 years), and they averaged 14.8 years of
postdegree clinical experience (range, 7 to 20 years). They had been practicing CT treatment
for an average of 9.5 years since their formal training, with a range of 8 to 12 years.

All four therapists had participated in at least one previous clinical trial in which they served
as research therapists for CT treatment. Despite their having previous experience, a year was
devoted to training the therapists in and piloting the component (BA and AT) treatments.
Three manuals were created for this study, one for each treatment condition. 2 All were based

4
 on the original CT manual ( Beck et al., 1979 ) but included specific guidelines for prescribed
and proscribed interventions in each treatment condition.

We developed a system for monitoring and calibrating for protocol adherence. One of the
coauthors (Keith S. Dobson) listened to a randomly determined 20% of all audiotaped
therapy sessions. Therapists were immediately contacted if a protocol violation occurred. In
addition, monthly meetings were held involving authors Neil S. Jacobson and Keith S.
Dobson, the project coordinator, and all therapists to discuss any ambiguities regarding
protocol or treatment integrity issues. Therapists were also encouraged to "flag" any
ambiguities in past sessions or any concerns they had about adherence in upcoming sessions.
Finally, as we describe later, adherence was systematically evaluated independently of these
calibration procedures.
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Treatments
BA condition.
In the Beck et al. (1979) CT manual, a common early strategy is to identify behavior
problems and to invoke a series of interventions designed to activate people in their natural
environment. These early strategies consist mostly of semistructured activities. Included in
the list of interventions considered to have an activation focus are (a) monitoring of daily
activities, (b) assessment of the pleasure and mastery that is achieved by engaging in a
variety of activities, (c) the assignment of increasingly more difficult tasks that have the
prospect of engendering a sense of pleasure or mastery, (d) cognitive rehearsal of scheduled
activities, in which participants imagine themselves engaging in various activities with the
intent of finding obstacles to the imagined pleasure or mastery expected from those events,
(e) discussion of specific problems (e.g., difficulty in falling asleep) and the prescription of
behavior therapy techniques for dealing with them; and (f) interventions to ameliorate
deficits in social skills (e.g., assertiveness, communication skills). In the BA condition,
activation is the exclusive focus for 20 sessions.

Activation and the modification of dysfunctional thoughts

(AT condition).
From a CT perspective, activation is only the first area that requires assessment and
modification in depression. Thus, although it was possible to structure an entire protocol
around this behavioral intervention, Beck et al. (1979) advocate that the therapist move
relatively quickly into cognitive interventions. A number of techniques have been developed
to identify and modify automatic dysfunctional thoughts. In particular, cognitive therapists
listen for "cognitive distortions," which are negative construals of different events that
precipitate sad feelings and depressed behavior. The CT therapist typically moves past
activation interventions to begin to assess these negative patterns of thinking and to teach
clients to be aware of them so that they can then be modified. Within this general framework,
a number of different techniques have been developed to assess and modify dysfunctional
thoughts. These include the following: (a) noticing mood shifts in therapy sessions and
asking for the thoughts that preceded the mood shift, (b) using a daily record of dysfunctional
thoughts as a form of personal diary in which the clients note particularly problematic events
and the types of thoughts that surrounded those events, (c) reexamining thoughts in specific
situations and determining whether the event warranted the types of conclusions that the

5
 patient had drawn about it, (d) helping clients learn how to respond in a more functional
manner to negative thinking, (e) examining the possibility of attributional biases or mistakes
in the way the clients see the causes of various successes and failures in their lives, and (f)
the development of homework assignments in which the clients assess the validity of their
negative interpretations. In this study, the AT condition permitted the use of all interventions
from the BA condition and those listed earlier. The only proscription in this condition was
the opportunity to work on underlying core beliefs or schemas.

CT condition.
CT, in its complete form, includes the identification and modification of more general
patterns of thought that are stable and presumably the causes of cognitive distortions and
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negative feelings. There are a number of specific interventions that are typical of therapists
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when they attempt to modify schema. They include the following: (a) use of the "downward
arrow," a technique in which the therapist asks the client for their explanations about why
certain problems have emerged, which then leads to the therapist hypothesizing various types
of general concerns and eventually to the identification of core beliefs; (b) the explicit
identification of underlying assumptions and core beliefs, either by direct report of the client
or by inference on the part of the therapist; (c) the identification of alternative assumptions or
core beliefs; (d) the discussion of the advantages and disadvantages of holding various
assumptions or core beliefs; (e) the discussion of the short-term versus the long-term
advantages of various assumptions or beliefs; (f) the assignment of homework that allows
patients to determine whether they actually use certain assumptions or core beliefs in the way
they deal with their life circumstances and to explore the application of other assumptions to
those circumstances; and (g) the use of the same techniques involved in modifying
dysfunctional thinking, except in this case they are applied to core beliefs rather to situation-
specific dysfunctional thinking.

In this study, the CT condition allowed the use of the full range of BA, AT, and CT
interventions. To ensure a fair test of the core schema hypothesis, however, we required that
a minimum of eight sessions have a primary focus on assumptive work.

Outcome Measures
All participants were evaluated before therapy, at the time of termination, and at 6-, 12-, 18-,
and 24-month follow-ups. In this article, we focus on the immediate effects of treatment and
on those at the 6-month follow-up. We include measures of depressive symptoms and the
presence or absence of major depression, which were based on reports from clients and from
clinical evaluators.

To assess the presence or absence of major depression at posttest, clinical evaluators gave
participants a modified version of the Longitudinal Interval Follow-Up Evaluation II (LIFE;
Keller et al., 1987 ), developed to assess the longitudinal course of psychiatric disorders. The
LIFE includes a semistructured interview that allows one to assess psychopathology over the
previous 6 months. In our modified version, criteria for the diagnosis of depression were
changed from the Research Diagnostic Criteria used on the original LIFE to those used in the
DSM—III—R. To determine presence or absence of major depression, we used weekly
psychiatric ratings on a scale ranging from 1 ( absence ) to 6 ( presence ). We used the LIFE
measure to determine whether participants continued to meet DSM—III—R criteria for major
depression at posttest.

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 Participants were also given the 17-item version of the HRSD, administered by a clinical
evaluator. This is a widely used interviewer-based measure of depression severity.

As a second self-report measure of depression severity, the BDI ( Beck et al., 1979 ) was
administered to participants before and after treatment. This is another widely used measure
of depression severity that correlates highly with the HRSD, has excellent psychometric
properties ( Beck, Steer, & Garbin, 1988 ), and is sensitive to clinical change ( Edwards et
al., 1984 ; Lambert, Shapiro, & Bergin, 1986 ).

Data Analysis
All analyses of outcome were conducted on those participants who completed at least 12
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sessions of treatment ("completers"), those who completed the maximum allotment of 20

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treatment sessions ("maximum completers"), and those who had at least one session of
therapy but dropped out before completing 12 treatment sessions ("dropouts"). For dropouts,
the last available score on each outcome measure served as the termination score. Posttest
HRSD and BDI scores served as the primary measures of depression severity. Analyses of
covariance, with pretreatment scores on the dependent measures used as covariates, were
applied to compare the efficacy of three treatments.

Treatment response was also analyzed categorically. To assess the percentage of participants
in each treatment condition who either recovered or improved but failed to recover, we
looked at the percentage who scored 8 or less on the BDI. These criteria, although arbitrary,
were recommended by Frank et al. (1991) in an effort to standardize measures of recovery in
depression research. 3 Participants were categorized as improved but not recovered if they no
longer met DSM—III—R criteria for major depression at posttest but continued to report BDI
scores greater than 8. Contingency table analyses were used to compare treatments in
improvement and recovery rates.

Results
Adherence to Treatment Protocols
The measure of treatment integrity used in the present study was a modified version of the
National Institute of Mental Health Collaborative Study Psychotherapy Rating Scale
(CSPRS; Hollon, Evans, Elkin, Lowery, 1984 ). Items included both techniques designated
by the treatment manual and those prohibited or proscribed by it. Ideally, the three treatment
conditions should have been most different on items reflecting interventions addressing the
modification of dysfunctional ATs and core schema, as all three conditions included BA.
Moreover, protocol violations should have been kept to a minimum. Our scale had 7 items
measuring the use of interventions focused on BA, 12 measuring work on ATs, and 7
measuring work on underlying assumptions (UA) or core schema, as well as 3 items
reflecting interventions that are proscribed in all three conditions. We were also interested in
"potency," that is, the ratio of interventions that are essential to the treatment to those that are
compatible with it but neither unique nor essential to CT ( Waltz, Addis, Koerner, &
Jacobson, 1993 ). Five items were added in the category ENU (essential but not unique to
BA, AT, or CT; e.g., setting an agenda, assigning homework) ; also, 11 items were added in
the category COMPAT, which reflected nonessential interventions that are compatible with
all conditions (e.g., skills training, assessing general functioning) but essential to none.

7
 Thus, the total scale had 45 items, grouped into the aforementioned six scales. Raters listened
to a tape of the therapy session, taking notes as they listened, and then rated each item on a
scale ranging from 0 ( not at all ) to 6 ( extensively or thoroughly ). Nine clients were
randomly selected from each condition for adherence ratings, for a total of 27 clients. For
each of these clients, one early, one middle, and one late session were randomly selected,
with sessions 1 and 20 excluded. Thus, a total of 81 tapes were rated.

Treatment condition was kept masked to trained coders. Intraclass correlation coefficients
were used to determine interrater reliability. The mean intraclass correlations were .81,
ranging from .73 to .89 across the six scales.

As Table 2 indicates, therapists were successful at keeping the treatments distinct. Therapists
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confined themselves to BA interventions in that condition and to BA and AT interventions in

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the AT condition and used all three types of interventions in the CT condition. The average
ratings were exactly as we had expected: BA items were common in all three conditions but
most common in the BA condition; AT interventions were common in both CT and AT
conditions; and work on core schema was common only in the CT condition. On an absolute
basis, almost no protocol violations were detected.

Another test of adherence involved asking the following question: Did the rate of occurrence
of BA, AT, and UA interventions exceed the random fluctuations expected by chance? This
question addressed whether the little bit of AT and UA work that occurred in BA and AT
conditions, respectively, differed significantly from the "noise level" that one would expect
by chance. Simultaneously, it allows one to be assured that the mean ratings of BA, AT, and
UA interventions differed significantly from zero when they were supposed to differ. There
were no statistically significant deviations from treatment protocols in any condition.

In the BA condition, only BA interventions significantly differed from zero, t (26) = 4.95, p
< .05. In the AT condition, both the AT intervention, t (26) = 3.89, p < .05, and the BA
intervention, t (26) = 3.63, p < .05, occurred to a significant degree, but UA interventions did
not, t (26) = 1.03, ns . However, in the CT condition, all three types of interventions occurred
to a statistically significant degree: For BA, t (26) = 4.61, p < .05; for AT, t (26) = 4.47, p
< .05; for CT, t (26) = 3.1, p < .05.

Finally, to compare the treatment conditions for potency, we examined the scale totals for
ENU, COMPAT, and PROSCR (proscribed), interventions. No significant between-group
differences emerged for any of these three scales.

Keith S. Dobson, who provided supervision for all therapists in the project, randomly
selected tapes in the CT condition and rated them for competence on the Cognitive Therapy
Scale (CTS), the accepted instrument for assessing competence in CT. The convention, albeit
arbitrary, is to use a score of 40 as the cutoff for competence on the CTS. The overall means
were above 40, as were the means for each therapist: For Therapists 1—4, M s = 45.16,
44.01, 47.91, and 46.17, respectively.

Treatment Outcome
Table 3 presents the means, standard deviations, and results of our primary outcome
analyses. Results are presented first for the total sample (including dropouts) and then for
each of three subsamples: maximum completers, completers, and dropouts. Pretreatment

8
 group differences were assessed through one-way analyses of variance (ANOVAs). With the
exception of the HRSD on the total sample, there were no significant pretreatment
differences between conditions.

The primary treatment outcome analyses consisted of 3 (Treatment Group) × 4 (Therapist)

multivariate analyses of covariance (MANCOVAs), with posttest BDI and HRSD scores
serving as dependent variables and pretest scores on the respective pretest measures serving
as covariates. The MANCOVAs for the total sample failed to uncover statistically significant
differences among treatments, F (4, 252) = 1, ns ; therapists, F (6, 252) = 1, ns ; or Therapist
× Treatment interactions, F (12, 252) < 1, ns . Similar MANCOVAs for the completers
showed group equivalence for treatments, F (4, 238) = 1, ns ; therapists, F (6, 238) < 1, ns ;
and Therapist × Treatment interactions, F (12, 238) < 1, ns . Finally, for the subsample of
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maximum completers, there were no differences among treatments, F (4, 226) = 1, ns ;

therapists, F (6, 226) < 1, ns ; or Treatment × Therapist interactions, F (12, 226) < 1, ns . To
protect familywise error rates, we chose .01 as our level of significance. However, none of
the MANCOVAs were significant at even the .05 level. Table 3 indicates the results of
ANCOVAs for each subsample and each measure. Because none of the therapist or Therapist
× Treatment interaction effects were significant, only the main effects for treatment are
presented in Table 3 . As indicated, there were no significant differences between the
treatments on either the BDI or the HRSD. When we looked at the results separately for each
therapist, we similarly found no differences among treatment conditions on either measure.

We also looked at the proportion of clients in each condition who improved and recovered to
assess the clinical significance of each treatment condition ( Jacobson, Follette, &
Revenstorf, 1984 ; Jacobson & Truax, 1991 ). Table 4 presents the improvement and
recovery rates for each of the treatments in each of the four samples. Chi-square analyses
revealed no significant differences between treatments on improvement or recovery in any of
the four samples. The mean improvement rate was 62.3% for the complete sample, 66% for
maximum completers, 58.3% for partial completers, and 16.7% for dropouts. The mean
recovery rate was 51.5% for the complete sample, 54.5% for maximum completers, 58.3%
for partial completers, and 5.6% for dropouts. Dropouts had significantly lower rates of
improvement and recovery than maximum completers ( χ 2 1, N = 141 = 7.8, p < .01 ; and χ 2
1, N = 141 = 9.5, p < .01 , respectively) and completers ( χ 2 1, N = 149 = 9.51, p < .01 ; and
χ 2 1, N = 149 = 7.8, p < .01 , respectively).

Six-Month Follow-Up Results

Table 3 includes follow-up scores on the BDI and the HRSD for all participants. We were
able to obtain follow-up data on all but one participant (a 99% retention rate). We conducted
ANCOVAs on both measures, with follow-up scores as the dependent variables and posttest
scores as covariates. This analysis provides a parametric test for changes during the follow-
up period on depressive symptoms as a function of treatment condition. The analyses found
that there were no significant differences between treatment conditions, F (2, 132) < 1, ns .
As Table 5 indicates, the treatments were also equivalent in the ultimate impact of therapy:
this conclusion is derived from ANCOVAs in which follow-up scores served as dependent
variables and pretest scores served as covariates. Thus, the three treatments did not differ
either in the overall impact of therapy through the 6-month follow-up or in changes in
depressive symptoms over the first 6 months after posttest.

9
 Table 5 shows the percentage of participants in each condition who had recovered during the
course of therapy and relapsed by the time of the 6-month follow-up, based on the LIFE
interview. Relapse was defined as meeting criteria for major depression, and we used three
different definitions of recovery: 8 consecutive weeks of not meeting criteria for major
depression, ending therapy with a BDI score of 8 or less, and ending therapy with an HRSD
score of 7 or less. Contingency table analyses indicated that, regardless of how recovery was
defined, groups did not differ significantly in relapse rates.

We also compared the recovered participants in all three treatment conditions on the number
of "well weeks" during the follow-up period, again using three criteria for recovery. A well
week was defined as a week when there were no or minimal symptoms, based on the LIFE
interview. The maximum score was 26. As Table 6 shows, there were no significant
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differences between treatment conditions, regardless of how recovery was defined.

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To summarize, none of our follow-up analyses uncovered differences between groups. CT

did not lead to decreased relapse, or better long-term functioning in terms of depressive
symptoms, than did either of the component treatments.

Mechanisms of Change
In this series of analyses, we took two approaches. First, we looked at the impact of each
treatment condition on the processes that it was expected to effect, as well as those allegedly
outside its domain; thus, we examined the degree to which each condition resulted in
increased behavioral activation, decreased negative thinking, and alterations in depressogenic
cognitive structures. Second, we tried to establish a temporal relationship between changes in
particular mechanisms and outcome. We used the Pleasant Events Schedule (both frequency
and pleasure ratings) as our measure of behavioral activation ( MacPhillamy & Lewinsohn,
1971 ), the Automatic Thoughts Questionnaire ( Hollon & Kendall, 1980 ) as our measure of
dysfunctional thinking, and the Expanded Attributional Style Questionnaire (EASQ; Peterson
& Villanova, 1988 ) as our measure of cognitive structures.

To examine the degree to which the three treatments resulted in mechanism changes, we
compared pre- and posttreatment scores on the three measures using paired t tests. When
clients were considered as an aggregate, there were significant improvements on each of
these mechanism measures. Clients in all conditions increased their frequency and
enjoyability of pleasant events; decreased their negative thinking; and showed significantly
lowered tendencies to attribute negative events to internal, stable, and global factors.

We examined differential outcomes based on treatment condition. We used ANCOVAs to

compare between-groups changes in these measures, with the pretreatment score on each of
the criterion variables serving as covariate. None of these measures changed differentially as
a function of treatment condition.

It was still possible that change in a mechanism could be a cause of later depression change
in one treatment and a consequence in another ( Hollon, DeRubeis, & Evans, 1987 ). One
way of evaluating this possibility was to examine the temporal relationship between change
in depression and cognitive and behavioral mechanisms. Again, following DeRubeis and
Feeley (1990) , we calculated residual change scores from pre- to midtreatment (early
change) and from mid- to posttreatment (late change) on both the BDI and each mechanism
measure. Table 7 shows the correlations between early residual change in cognitive and

10
 behavioral mechanisms and late residual change in depression in each treatment. Contrary to
what was expected, early change in two subscales of the EASQ were associated with later
change in the BA but not in the CT treatment. Participants in the BA treatment who made
less negative attributions early in treatment became less depressed later in treatment. Also
contrary to expectation, early change in frequency of pleasant events was associated with
later change in depression in the CT treatment but not in the BA treatment.

We also examined the correlations between early residual change in depression and late
residual change in cognitive and behavioral mechanisms. Early change in depression was not
significantly related to later change in the EASQ or the PES in either of the treatment
conditions.
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Discussion
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We found no evidence in this study that CT is any more effective than either of its
components. When one examines the means and standard deviations on our outcome
measures, the null findings are unlikely to be attributable to inadequate power. The outcomes
were quite comparable across treatment conditions and across outcome measures. Given the
fact that our criteria for recovery were more stringent than in many previous studies, it is
hard to compare the outcomes of this and other studies. However, our recovery rates were
comparable with those of the TDCRP; despite a more severely depressed sample in this
treatment study than in the TDCRP (as evidenced by higher mean BDI scores), the
magnitude of change for participants in this study was comparable with those of previous CT
studies.

The finding that BA alone is equal in efficacy to more complete versions of CT is important
for both the theory and treatment of depression. We have ruled out threats to the internal
validity of this study, and to the results given earlier, suggesting that these are valid findings:
Our competence ratings showed that the therapists were performing CT within the range
typically viewed by experts as competent; also, the absence of superiority for CT is not
accounted for by unwanted overlap between treatments. The adherence ratings suggest that
the treatments were quite discriminable and that the therapists did an excellent job of sticking
to the treatment protocols. Thus, despite the fact that the treatments were distinct, the
outcomes were indistinguishable, at least in the short term.

Furthermore, the treatments were not significantly different at follow-up. The parametric
analyses included the entire sample, thus preserving random assignment. With these
analyses, there were no overall differences between groups at the time of the 6-month follow-
up, and groups did not change differentially during the follow-up period. All groups
maintained their treatment gains for the most part during the short follow-up period. When
relapse rates were examined, either parametrically in terms of the number of well weeks or
nonparametrically in terms of the proportion of participants who had relapsed, CT once again
failed to outperform component treatments.

Thus, participants with depression who received BA alone did as well as those who were
additionally taught coping skills to counter depressive thinking. Furthermore, both
component groups improved as much as those who received interventions aimed at
modifying cognitive structures, specifically underlying assumptions, and core schema. These
findings run contrary to hypotheses generated by the cognitive model of depression put forth
by Beck and his associates (1979) , who proposed that direct efforts aimed at modifying

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 negative schema are necessary to maximize treatment outcome and prevent relapse. These
results are all the more surprising, given that they run counter to the allegiance effect
( Robinson, Berman, & Neimeyer, 1990 ), which is quite commonly related to outcome in
psychotherapy research. All of the therapists expected CT to be the most effective treatment,
and morale was low whenever a case was assigned to BA. Moreover, Keith S. Dobson, one
of the clinical supervisors in the TDCRP, expected CT to outperform the alternative
treatments. In short, although the null hypothesis can never be accepted, especially in
response to one study with negative findings, the distinctiveness of the treatments as well as
the allegiance of the therapists and supervisor make the absence of a treatment effect more
convincing than would otherwise be the case.

These results raise questions as to the theory of change put forth in the CT book by Beck and
his associates. They also raise questions as to the necessary and sufficient conditions for
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change in CT. These questions are more pronounced in light of the failure to find evidence
that the mechanisms addressed by the various treatments were associated with differential
change in the targeted mechanisms. In fact, our analyses of moderator effects yielded the
counterintuitive finding that changes in attributional style were most inclined to be followed
by decreased depression in BA, not in CT, as one would expect given the cognitive theory of
change. It seems as if clients who responded positively to activation were also those who
altered their predictions regarding how they would respond to negative life events that might
occur. Because this was not a predicted finding, it should be interpreted with caution.
Nevertheless, if measures of attributional style are thought of as predictions regarding
hypothetical future encounters rather than measures of cognitive structure, it may be that
patients with depression who respond positively to activation instructions are also those who
make more optimistic predictions once they are provided with interventions designed to place
them in touch with potential sources of positive reinforcement. Of course, it is also possible
that BA-focused treatments are more effective ways of changing the way people think than
treatments that explicitly attempt to alter thinking. Perhaps the exposure to naturally
reinforcing contingencies produces changes in thinking more effectively than the explicitly
cognitive interventions do.

If BA and AT treatments are as effective as CT and also are as likely to modify the factors
that are thought to be necessary for change to occur, then not only the theory but also the
therapy may be in need of revision. Both BA and AT are more parsimonious treatments than
CT and might be more accessible to less experienced or paraprofessional therapists. Because
the intervention choices are fewer and more straightforward, these component treatments
may also be more amenable to less costly alternatives to psychotherapy, such as self-
administered or peer support treatments (cf. Christensen & Jacobson, 1993 ).

Many questions need to be answered before one can draw negative conclusions about the
theory of change put forth by Beck et al. (1979) . For one thing, it may be that CT will prove
to be effective in preventing recurrence relative to the component treatments. If that proves to
be the case, we have shown that the schema modification component of CT has a
prophylactic effect, although it may not facilitate acute treatment response. As our 12-month,
18-month, and 2-year follow-up data come in, we will be able to compare the treatments in
terms of their relapse—recurrence prevention.

Finally, we acknowledge current limitations in our ability to measure the constructs that were
targeted for intervention by the three treatment conditions. It could be that the absence of an
association between treatment condition and target mechanism has more to do with the
inadequacy of currently available measuring instruments than with the absence of differential

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 change mechanisms. This concern is especially acute for measures of negative schema, in
which paper-and-pencil measures have been criticized. We recognize the limitations of these
methods and acknowledge that if proper measures existed the association between
mechanism and treatment condition might indeed be stronger.

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¹Sample sizes differ for some analyses because of missing data.

²These manuals are available from Neil S. Jacobson.

³Results were virtually unchanged when alternative criteria recommended by Frank et al.
(1991) were adopted: HRSD scores less than 7 or at least 8 weeks of not meeting criteria for
major depression.

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