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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.
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relationships. He felt people rejected him and he was unable to achieve closeness with others. According to Beck
Depression Inventory (BDI) scores, he was no longer depressed at the end of our treatment, and reported making progress in being more intimate with his wife and
children. In this excerpt from the last session, Mr. G. describes how he experienced the two types of therapy and
what he learned:
There's a lot of stuff going on in my personal life
that we've been working on here in depression and
so on, and that has led to maybe the cognitive therapy way of handling things and looking a t . . . , you
know, the daily activity log and then doing the
t h o u g h t records and analyzing thoughts and how
they lead to things. So that's over here [with the
first 8 sessions of CT]. And then on this other part,
which I definitely got into with you [the second 12
sessions o f FECT], was in my personal relationships
and how that works, on both sides, myself and the
other person. And then it became how that
occurred for you and me as an example of [my
appearing to others as] ominous. It's something I
learned with you so that it would not persist in
unintentionally coloring my relationships.
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1077-7229/02/213-22951.00/0
Copyright 2002 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
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Kohlenberg et al.
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(a)
r-->
(b)
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(c)
FECT
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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 int e n d e d to be user-friendly for e x p e r i e n c e d cognitive therapists, a n d rely u p o n the skills, training, forms, procedures, 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
(1979) widely p r a c t i c e d a n d empirically validated treatm e n t for depression. T h e two major FECT enhancements 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 rationale for the causes a n d t r e a t m e n t of depression and
(b) a greater use o f the client-therapist relationship as an
in vivo teaching opportunity.
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1Technically, the term cognition refers to cognitive products, structures, or processes (Hollon & K~iss, 1984). Due to space limitations,
we have not made this distinction here, but we have shown elsewhere
that our analysis is consistent with the more technical meanings of
cognition (Kohlenberg & Tsai, 1991, chapter 5).
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corresponds to one of the other paradigms shown in Figure 1, standard cognitive therapy might result in a clienttherapy mismatch and a less effective treatment. It is also
possible that multiple paradigms exist for a given client,
or that paradigms change from situation to situation.
The use of the e x p a n d e d rationale is illustrated in the
case of a client, Mr. D. Mr. D. had a problem of getting
angry too easily. He b r o u g h t up an example of getting angry at other drivers at a four-way stop while driving to his
appointment. He explained how the driver in front of
him could have moved forward a little and allowed Mr. D.
to make a right-hand turn. In this example, the therapist
does a brief assessment to determine if A-B-C or an alternate paradigm should also be considered in Mr. D.'s
treatment:
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215
2.16
Kohlenberg et al.
and noted that situations when these opportunities occur
are "more powerful than imagined or described" situations (p. 71). The same idea is found in the widely accepted notion that in vivo exposure treatment is more
powerful than in-office treatment. This FAP view of the
client-therapist relationship differs both from the notion
of collaboration in cognitive therapy and from therapeutic alliance (Callaghan, Naugle, & Follette, 1996; Follette
et al., 1996; B. S. Kohlenberg, Yeater, & Kohlenberg,
1998). Although there are thndamental theoretical differences between FAP and psychoanalysis (see R. J.
Kohlenberg & Tsai, 1991, chapter 7), the notion of CRBs
as special opportunities for therapeutic change has much
in c o m m o n with the psychoanalytic concept of working
with transference (R.J. Kohlenberg & Tsai, 1994).
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lar response not an instance of the client's daily life problems? This process of noticing potential CRBs is essential
to FECT, and is sharpened by the use of the case conceptualization form as discussed below.
Co
217
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
with the therapist. It was in this c o n t e x t that MI: G.'s "ominous" 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.
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 exp r e s s e d w a r m t h toward Mr. G.
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Corresponding cognitive concepts (cognitive CRBls: automatic thoughts, core beliefs, underlying assumptions). Mr. G.
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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
Table 2
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Middle of Therapy
I'm having a hard time expressing myself a b o u t . . .
I want you to know...
It would be difficult for me to f a c e . . .
I am interested in changing my therapy to include...
I could improve our relationship b y . . .
Yon could improve our relationship b y . . .
I have a hard time expressing myself a b o u t . . .
It is hard for me to tell you a b o u t . . .
What bothers me about you i s . . .
Doesn't nleasure up
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Incompetent
Ineffective
Inferior
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Inadequate
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Failure
End of Therapy
For many clients, the end of therapy brings up feelings and
memories of previous transitions and losses. What thoughts
and feelings do endings in general bring up for you?
What thoughts and feelings are you having about the ending of
this therapy relationship?
What have you learned, what has been helpful for you in this
therapy?
What stands out to you most about yonr interactions with your
therapist?
What do you like and appreciate about your therapist?
What regrets do you have about the therapy or what would you
like to have gone differently?
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Anticipated CRB
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Core Issue
Table I
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Table 3
Useful Sample Questions to Evoke CRB
Table 4
Sample Questions for Use During Supervision of FECTTherapists
to Increase Self-Awareness
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Kohlenberg et al.
d e n o t i n g the thoughts, feelings, a n d actions that occ u r r e d in response to the particular event in daily life, the
client is asked, "How might similar p r o b l e m a t i c thoughts,
feelings, a n d / o r actions c o m e up in session, a b o u t the
therapy, o r between you a n d your therapist?"
Third, a new column, "Alternative, More Productive
Ways o f Acting" asks clients to come up with alternative
ways of acting that would help t h e m achieve their goals.
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
Act More Effectively" using the following scale:
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Therapists
O u r research therapists h a d b e e n in practice for at
least 10 years a n d h a d served as cognitive therapy research therapists on p r i o r clinical trials. T h r e e therapists
were psychologists; o n e was a social worker. Two therapists were b o a r d certified by the A c a d e m y o f Cognitive
Therapy.
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Procedure
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Measures
We wanted to measure several different classes o f variables in this study. First, we wanted o u r study to be comparable 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
depression, so traditional o u t c o m e measures were used
(e.g., Elkin et al., 1989). We used (a) the 17-item Hamilton Rating Scale for Depression (HRSD; Hamilton, 1967);
(b) the Global Assessment of F u n c t i o n i n g Scale ~GAF;
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Clients
Eligibility criteria were a diagnosis of major depressive
d i s o r d e r a c c o r d i n g to the Structured Clinical Interview
for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams,
1995) a n d a score of 18 o r greater on the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, &
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
J a c o b s o n et al. (1996).
Participants were recruited t h r o u g h c o m m u n i t y clinic
referrals a n d newspaper advertisements. After an initial
p h o n e screening, participants were given a full diagnostic
evaluation to d e t e r m i n e study eligibility. O f the 116 par-
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Method
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Empirical Findings
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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
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BDI
HRSD
21.65 +- 5.36
8.61 -+ 5.45
7.83 -+ 4.76
.20
.30
.28
.17
23
23
23
14.65 -+ 3.75
5.52 -+ 4.54
4.04 -+ 3.69
.O6
.40
.53
.08
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%
( 8 / 1 5 ) o f C T clients (X2 = 4.03, p = .049).
0.92 -+ 0.42
0.54 -+ 0.42
0.66 + 0.37
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18b
17a
0.89 +- 0.35
0.35 -4- 0.20
0.46 + 0.43
.06
.10
.61
.48
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
BDI 8 o r less w e r e n o t statistically s i g n i f i c a n t
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
54.67 +- 5.23
70.27 +- 15.52
78.87 +- 11.42
23
23
23
55.09 -+ 7.82
73.13 +- 13.79
85.39 +- 9.52
.29
.03
.19
.65
M + SD
Pre
Post
Follow-up
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15
15
21.67 +- 8.09
10.67 +- 10.03
8.87 + 7.43
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23
23
Pre
Post
Follow-up
15
15
15
14.93 +- 4.06
8.60 + 7.12
4.47 + 4.24
Pre
Post
Follow-up
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11a
13c
Pre
Post
Follow-up
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15
15
M +- SD
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
m i s s i o n o f 67%. E i g h t e e n o f 23 (78.3%)
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
only with t h e H R S D c r i t e r i o n .
Relapse analyses. S i n c e we o n l y h a d a 3-
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
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
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 -
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GAF
ES
FECT
Time
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SCL-90
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 outc 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
d i d CT o n all m e a s u r e s .
CT
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Note. p = p value for between condition ANCOVA; ES = Effect size; BDI = Beck Depression
Inventory; HRSD = 17-item Hamilton Rating Scale for Depression; SCL-90 = Symptom
Check-List 90, total score; GAF = Global Assessment of Functioning.
aFour CT clients did not return their post-treatment assessment packets (which included the
SCL-90 and SAD).
b Five FECT clients did not return their post-treatment assessment packets (which included
the SCL-90 and SAD).
c Two CT clients did not return their 3-month follow-up assessment packets (which included
the SCL-90 and SAD).
~Five FECT clients did not return their 3-month follow-up assessment packets (which included
the SCL-90 and SAD), and one client did not return the SCL-90 with the follow-up assessment
packet.
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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
study, was n o t clinically d e p r e s s e d at t h e e n d
o f a c u t e t r e a t m e n t ( H R S D < 13), a n d remained
the
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
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
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 -
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depression-free throughout
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 .
50
[] CT
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HRSD
SCL90-T
GAF
HRSD
SCL90-T
Outcome measure
GAF
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Endicott, Spitzer, Fleiss, & Cohen, 1976); (c) the Beck Depression Inventory (BDI; A. T. Beck et al., 1961); a n d (d)
the Symptom Checklist-90 Total Score (SCL-90; Derogatis, Lipman, & Covey, 1973). These four measures are established instruments for the m e a s u r e m e n t of depressive
symptoms (BDI a n d HRSD), overall symptoms (SCL-90
T), a n d general level of f u n c t i o n i n g (GAF). All measures
were administered at pretreatment, posttreatment, a n d at
a 3-month fbllow-up. The HRSD a n d GAF were completed by a trained evaluator at p r e t r e a t m e n t a n d followup a n d by the therapist d u r i n g the final session. Also, to
assess diagnostic status a n d relapse rates at the 3-month
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
Follow-up Evaluation (LIFE; Keller et al., 1987), a semistructured retrospective interwiew that assesses the longitudinal course of depression a n d other disorders.
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 measures of interpersonal functioning. We administered the
Social Support Q u e s t i o n n a i r e (SSQ; Sarason, Levine,
Basham, & Sarason, 1983), a well-validated measure that
asks subjects to list up to n i n e individuals to whom subjects feel they could turn for support in each of six different situations a n d to rate their satisfaction with available
support for each situation on a 6-point Likert scale. The
m e a n n u m b e r of individuals a n d m e a n satisfaction ratings across the six situations are used as subscale scores.
We also administered the Social Avoidance and Distress
Scale (SAD; Watson & Friend, 1969). Although the SAD
is widely used in t r e a t m e n t research on social phobia, we
believe it has relevance to depression in general a n d to
FECT treatment of depression in particular. This is because a behavioral view of depression specifically emphasizes a lack or avoidance of social reinforcers (Boiling,
Kohlenberg, & Parker, 2000; Lewinsohn, 1974), a n d overc o m i n g social avoidance is targeted in both FECT a n d
Behavioral Activation treatments for depression.
We also wanted a measure of relationship satisfaction
that tracked progress weekly t h r o u g h o u t therapy. Before
b e g i n n i n g each therapy session, clients responded to two
questions (in a confidential, sealed questionnaire that
the therapist did n o t see) a b o u t their interpersonal relating d u r i n g the previous week. The first question was,
"Have your relationships b e e n different than usual?" Clients were asked to respond to this question on a 5-point
scale (1 = much worse, 3 = no change, a n d 5 = much better).
T h e second question was, "If your relationships are different this week, is this difference due to therapy?" Clients
were asked to respond o n a 4-point scale (1 = due to other
factors, 4 = definitely due to therapy).
We also c o n d u c t e d several intensive videotape rating
projects to assess additional client reactions a n d changes
not assessed by existing measures. First, we were inter-
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Results
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Major Outcomes
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Statistical significance. We first tested for statistical significance of m e a n differences between t r e a t m e n t conditions on the four major outcome measures using ANCOVA,
with pretreatment scores on each measure entered as covariates. Table 5 shows sample sizes, means a n d standard
deviations for CT a n d FECT on the four measures at pretreatment, posttreatment, a n d follow-up. Table 5 also
shows the p value ( o n e - t a i l e d ) for each ANCOVA comparing CT a n d FECT. Results favored FECT at all time
points, with a significant difference f o u n d o n the GAF at
follow-up, and trends f o u n d on the HRSD a n d SCL-90 at
posttreatment.
Effect sizes. Because of small sample size, we were particularly interested in effect sizes as measured by d, a n d
used adjusted values as instructed by C o h e n (1988, p.
380). Across all measures (see Table 5), the m e a n posttreatment effect size was .40, a n d the m e a n follow-up effect size was .34.
Clinical significance. W e also split our clients into
groups of "responders" a n d "failures." We defined responders as those with a clinically significant reduction in
depressive symptoms, defined as greater than or equal to
50% reduction in overall symptom severity measured at
pretreatment. Figure 2 shows the percentage of responders in CT a n d FECT for each outcome measure. FECT
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223
A
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attributions for change over the course of therapy. (A) Mean ratings 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.
(B) Mean ratings on question: If your relationships are different
this week, is this difference due to therapy? 1 = due to o t h e r
factors, and 4 = definitely due to therapy.
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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
points.
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 relating 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
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 relationships 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.
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
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 .
O u r d a t a s u p p o r t e d this possibility. At posttest, t h e
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
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 assessments) 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
M +- SD
ES
Pre
Post
Follow-up
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11
13
4.02 -+ 1.48
4.08 - 1.61
4.05 -+ 1.66
23
18
18
4.04 +- 1.42
4.69 -+ 0.92
4.76 _+ 1.24
.97
.01
.01
.91
.99
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Table 6
SSQ Relationship Satisfaction Subscale Scores by Condition,
p Values, and Effect Sizes
Kohlenberg et al.
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Reaction to Rationale
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Figure 5.
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Enhancing Cognitive
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the SCID to the LIFE. Raters were b l i n d to t r e a t m e n t condition a n d to o t h e r client outcomes. A 7-point scale with
verbal anchors (ranging from 1 = much worse, 4 = no
change in relationships, to 7 = much improved) was used. To
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
scored three clients that the o t h e r rater h a d i n d e p e n dently scored, with 100% a g r e e m e n t .
Because the range o f scores was restricted (no client
was r a t e d as 1, 2, o r 7, a n d only 1 client was rated 3), ratings were t h e n categorized as either "improved" (scores
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
4). Results indicate that relationships i m p r o v e d significantly m o r e frequently for FECT (85%, 17/20) clients
than for CT (53%, 8 / 1 5 ) clients, X2 = 4.21, p = .047.
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225
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E x p l o r i n g daily life assumptions: T h e r a p i s t explores with the client a g e n e r a l belief that underlies
many of the client's specific automatic negative
thoughts in daily life.
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Measure and
Subscale
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Change
p Value
.10
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4.26
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.50
.99
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.02
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1.28
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2.00
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SAD
In vivo
FAP
CT
IPT
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BDI
In vivo
FAP
CT
IPT
R2
Change
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Summaly and C o n c l u s i o n
te
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(Note that this result is statistically e q u i v a l e n t to finding a significant [3 only for the In Vivo subscale in the
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
simultaneously.)
To assess the relationship between THISS subscale
scores a n d i n t e r p e r s o n a l outcomes, a similar set o f equations were evaluated using SAD pre- a n d p o s t t r e a t m e n t
scores instead o f BDI scores, with similar results. SAD pretest scores a c c o u n t e d for 50% o f the variance, a n d the
subscales a c c o u n t e d for an additional 11%. Table 7 shows
that the In Vivo subscale uniquely a c c o u n t e d for most o f
this additional variance (R 2 c h a n g e = .09) a n d the o t h e r
subscales h a d negligible contributions. T h e In Vivo subscale'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
change (1, 23) = 5.38, p = .03, a n d no o t h e r subscales
were significant contributors.
227
228
Kohlenberg et al.
References
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gr
Watson, D., & Friend, R. (1969). Measurement of sociabevaluative anxiety.Journal of Consulting and Clinical Psychology, 33, 448-457.
Young, J. E. (1990). Cognitive therapy for personality disorders: A schemafocused approach. Sarasota, FL: Professional Resource Exchange.
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