The Use and Nature of Present-Focused Interventions in Cognitive and Behavioral Therapies for Depression.

Both cognitive therapy (CT; Beck, Rusch, Shaw, & Emery, 1979) and behavioral activation (BA; Martell, Addis, & Jacobson, 2001) for depression are considered to be empirically supported (DeRubeis & Crits-Christoph, 1998; Dobson, 1989; Ekers, Richards, & Gilbody, 2008). However, both approaches leave ample room for improvement, in terms of acute response, remission, and prevention of relapse and recurrence (e.g., Gortner, Gollan, Dobson, & Jacobson, 1998; Jacobson et al., 1996). For example, in a recent meta-analysis of 12 trials comparing behavior therapy and cognitive therapy, it was found that at the end of treatment only 55% of clients were classified as recovered (Ekers et al., 2008). In response to such data, multiple efforts to modify, present alternatives to, and otherwise improve cognitive and behavioral therapies (CBT) are occurring. One avenue for improvement has been an increased focus on the occurrence of problems as they occur in the here-and-now therapy moment (e.g., in relation to the therapeutic relationship or therapy process), which we refer to as present-focused. This is not to say the present moment is ignored in CBT. In CT for depression, for example, the therapeutic relationship has been seen as an important common factor, necessary for the establishment of collaborative empiricism but not the core mechanism of change (Goldfried & Davila, 2005; Waddington, 2002). Traditional CT manuals (Beck et al., 1979; J. Beck, 1995) note the importance of establishing a strong collaborative relationship, contain instructions for how to resolve difficulties and impasses in the relationship, and include several examples of relationship-focused interactions. The relationship in BA is similar—the therapist is seen as a coach or collaborator with the client, but the relationship is not conceptualized as an active mechanism of change (Martell et al., 2001). In other words, in both CT and BA, the relationship is an implicit rather than explicit priority. Likewise, CT and BA's focus on the therapy process is clearly articulated but not seen as essential to the change process. At the beginning and end of sessions, therapists are encouraged to discuss the therapy process and elicit feedback from the client about how he or she is reacting to the process. This feedback serves to identify whether the client understands what the therapist is saying and to elicit potentially counter-productive client responses to the treatment (e.g., Beck et al., 1979, pp. 100–101). In addition, CT therapists are taught to see “hot cognitions” and current emotions as opportunities for key cognitive changes to occur. The primary focus in traditional CBT approaches, however, is on changing thoughts and behavior related to the world outside of therapy, not in relation to the here-and-now therapy moment, the therapy relationship or the therapy process. Several recent CBT variants shift these priorities and emphasize the present moment in specific ways linked directly to core change processes. These treatments include J. Beck's (2005) approach to CT for challenging problems, Leahy's (2001) guidelines for overcoming resistance in CT, the Cognitive-Behavioral Analysis System of Psychotherapy (CBASP; McCullough, 2000), Cognitive Therapy for Personality Disorders (CT-PD; Beck, Freeman, Davis, & Associates, 1990), Schema Focused Therapy (SFT; Young, 1999), Short Term Cognitive Therapy (STCT; Newman, 1998), and Integrated CT (Castonguay et al., 2004). In addition, Functional Analytic Psychotherapy (FAP; Kohlenberg and Tsai, 1991; Tsai et al., 2008) has been suggested as a framework with which to enhance the therapeutic relationship, and therefore outcomes in CT (resulting in FAP-Enhanced CT, or FECT; Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002; Kohlenberg & Tsai, 1991) and BA (FAP-Enhanced BA, or FEBA; Kanter, Manos, Busch, & Rusch, 2008). While these treatments vary from each other in terms of the theoretical models that underlie the specific present-focused techniques incorporated, they share a common emphasis on work within the present moment as a proposed active mechanism of change. Much, but not all, of the emphasis in these newer treatments is on the therapy relationship or therapeutic alliance. For example, Integrated CT (Castonguay et al., 2004) provides techniques for therapists to identify, explore and address alliance ruptures as they arise in therapy, with the goal being a client's direct exploration of their feelings toward the therapist, followed by therapist empathic validation. CBASP (McCullough, 2000), STCT (Newman, 1998), CT-PD (Beck et al., 1990), FECT (Kohlenberg et al., 2002), and FEBA (Kanter et al., 2008), focusing more broadly on the therapy relationship than just the alliance per se (Gelso & Samstag, 2008; Lejuez, Hopko, Levine, Gholkar, & Collins, 2005), also emphasize identifying and resolving problems that may occur between the client and therapist as key facets of treatment. For example, CBASP (McCullough, 2000) contains detailed instructions for dealing with a host of issues that may disrupt the therapeutic alliance, including therapist feelings of frustration and incompetence, client resistance to the therapeutic work, lack of client improvement, hostile and angry clients, and passive-dependent clients. Similarly, STCT (Newman, 1998) specifically highlights potential alliance ruptures due to clients feeling a loss of autonomy and control to the therapist, feeling rushed into tasks before they are ready, and anticipating that abandonment will occur when the therapy relationship ends, among other issues. CT-PD (Beck et al., 1990) likewise focuses on problems with non-collaboration in the therapeutic relationship, offering a number of strategies to target and explore possible causes of non-collaboration, including, but not limited to, lack of client skill, the role of culture, dysfunctional beliefs, poor timing of interventions, problems with goals of therapy, and client or therapist frustration with lack of progress. Several approaches, including SFT (Young, 1999), CT-PD (Beck et al., 1990), STCT (Newman, 1998), and FECT (Kohlenberg et al., 2002) stress the importance of present-focused cognitive restructuring, wherein therapists pay particular attention to clients' immediate emotional reactions to the therapist, therapy process, or other aspects of the present moment and apply cognitive restructuring strategies, including the use of dysfunctional thought records, as these reactions occur. These strategies are largely consistent with traditional CT techniques; the primary difference is that the beliefs targeted for change are in-session present-focused beliefs rather than beliefs about daily life events and relationships. Another common theme is strategic therapist self-disclosure, advocated by BRT (Safran & Segal, 1990), SFT (Young, 1999), STCT (Newman, 1998), FECT (Kohlenberg et al., 2002), FEBA (Kanter et al., 2008), and CBASP (McCullough, 2000). The rationale for disclosure varies; some employ it to challenge maladaptive and present-focused cognitions (e.g., SFT, STCT, and FECT), while others employ therapist self-disclosure of reactions to client behavior as punishment or reinforcement (e.g., CBASP, FECT, and FEBA). Finally, several approaches, including CBASP (McCullough, 2000), FECT (Kohlenberg et al., 2002), and FEBA (Kanter et al., 2008) highlight the importance of comparing and contrasting present-focused interactions with daily life situations. This is seen as important both in generating hypotheses about potential transference reactions or other present-focused situations requiring therapeutic attention, as well facilitating generalization of gains made during present-focused interactions to daily life. Research on the use of present-focused interactions in these approaches is limited but encouraging, and largely consists of research on the therapy relationship. Of all of the treatments highlighted above, CBASP is the most empirically supported. In a large trial, CBASP performed as well as nefazadone (Keller et al., 2000) and was effective at preventing relapse (Klein et al., 2004). Furthermore, the best predictor of positive outcomes for CBASP was the overall degree of emphasis therapists placed on discussing the therapeutic relationship (Vocisano et al., 2004). In addition, FECT has been evaluated in one non-randomized trial (Kohlenberg et al., 2002) compared to CT. In this trial, both CT and FECT performed equally, however FECT clients demonstrated large improvements on several measures of interpersonal functioning compared to CT clients. Additional analyses of the FECT study suggested that present-focused interventions, broadly defined, predicted client-reported progress during treatment (Kanter, Schildcrout, & Kohlenberg, 2005), and present-focused cognitive restructuring specifically predicted improved outcomes at the end of treatment (Kohlenberg et al., 2002). ICT has been evaluated in two trials. The first (Castonguay et al., 2004) compared ICT to a wait-list control, with encouraging results, and the second (Constantino et al., 2008) compared ICT to traditional CT. In this trial, ICT performed well, evidencing improved depression rates, fewer dropouts, better perceived alliances, and higher perceived therapist empathy compared to traditional CT.