Cognitive Therapy and Research

, Volume 29, Issue 6, pp 803–817 | Cite as

The Therapeutic Alliance and CBASP-Specific Skill Acquisition in the Treatment of Chronic Depression

  • Neil J. Santiago
  • Daniel N. KleinEmail author
  • Dina Vivian
  • Bruce A. Arnow
  • Janice A. Blalock
  • James H. Kocsis
  • John C. Markowitz
  • Rachel Manber
  • Lawrence P. Riso
  • Barbara O. Rothbaum
  • A. John Rush
  • Michael E. Thase
  • James P. McCulloughJr.
  • Martin B. Keller


This study examined the influences of proposed specific and common psychotherapeutic factors in a sample of chronically depressed adult outpatients. Participants (N = 324) were drawn from a multi-site clinical trial that compared the efficacies of the cognitive behavioral analysis system of psychotherapy (CBASP), nefazodone, and their combination. This report is limited to patients receiving CBASP alone or combination treatment. A series of regression analyses were performed to test whether: (1) the ability to utilize the skills taught in CBASP mediated the relationship between the early therapeutic alliance and endpoint depression, and (2) the therapeutic alliance moderated the relationship between skill utilization and endpoint depression. Neither model was supported. Instead, each of these factors contributed independently and additively to alleviation of depressive symptoms.

Key Words

psychotherapeutic processes therapeutic alliance chronic depression cognitive therapy 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Ahn, H., & Wampold, B. E. (2001). Where oh where are the specific ingredients? A meta analysis of component studies in counseling and psychotherapy. Journal of Counseling Psychology, 48, 251–257.CrossRefGoogle Scholar
  2. Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. Thousand Oaks, CA: Sage Publications.Google Scholar
  3. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC, US: American Psychiatric Association.Google Scholar
  4. Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173–1182.PubMedCrossRefGoogle Scholar
  5. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.Google Scholar
  6. Bordin, E. S. (1979). The generalizability of the psychoanalysis concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16, 252–260.Google Scholar
  7. Burns, D. D., & Nolen-Hoeksema, S. (1992). Therapeutic empathy and recovery from depression in cognitive-behavioral therapy: a structural equation model. Journal of Consulting and Clinical Psychology, 60, 441–449.PubMedCrossRefGoogle Scholar
  8. Busseri, M. A., & Tyler, J. D. (2003). Interchangeability of the Working Alliance Inventory and Working Alliance Inventory, short form. Psychological Assessment, 15, 193–197.Google Scholar
  9. Butler, S. F., & Strupp, H. H. (1986). Specific and nonspecific factors in psychotherapy: A problematic paradigm for psychotherapy research. Psychotherapy: Theory, Research, Practice, Training, 23, 30–40.Google Scholar
  10. Castonguay, L. G. (1993). “Common factors” and “nonspecific variables”: Clarification of the two concepts and recommendations for research. Journal of Psychotherapy Integration, 3, 267–286.Google Scholar
  11. Castonguay, L. G., Goldfried, M. R., Wiser, S., & Raue, P. J. (1996). Predicting the effect of cognitive therapy for depression: A study of unique and common factors. Journal of Consulting and Clinical Psychology, 64, 497.PubMedCrossRefGoogle Scholar
  12. Chatoor, I., & Krupnick, J. (2001). The role of non-specific factors in treatment outcome of psychotherapy studies. European Child and Adolescent Psychiatry, 10(Suppl 1), I19–25.PubMedCrossRefGoogle Scholar
  13. Constantino, M. J., Castonguay, L. G., & Schut, A. J. (2002). The working alliance: A flagship for the “Scientist-practitioner” model in psychotherapy. In G. Tryon (Ed.), Counseling based on process research. New York: Allyn & Bacon.Google Scholar
  14. DeRubeis, R. J., & Feeley, M. (1990). Determinants of change in cognitive therapy for depression. Cognitive Therapy and Research, 14, 469–482.CrossRefGoogle Scholar
  15. DeRubeis, R. J., Tang, T. Z., Gelfand, L. A., & Feeley, M. (2000). Recent findings concerning the processes and outcomes of cognitive therapy for depression. In P. M. McCabe (Ed.), Stress, coping, and depression (pp. 223–240). Mahwah, NJ: Lawrence Erlbaum Associates.Google Scholar
  16. Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., et al. (1989). National institute of mental health treatment of depression collaborative research program. General effectiveness of treatments. Archives of General Psychiatry, 46, 971–982; discussion 983.Google Scholar
  17. Fawcett, J., Epstein, P., Fiester, S. J., Elkin, I., & Autry, J. H. (1987). Clinical management—imipramine/placebo administration manual. NIMH Treatment of Depression Collaborative Research Program. Psychopharmacology Bulletin, 23, 309–324.PubMedGoogle Scholar
  18. First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). Structured clinical interview for DSM-IV Axis II disorders (SCID-II). Washington, DC: American Psychiatric Press.Google Scholar
  19. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995). Structured clinical interview for DSM-IV Axis I disorders - Patient edition (SCID-I/P, Version 2.0). New York: Biometrics Research Department, New York State Psychiatric Institute.Google Scholar
  20. Gaston, L., Marmar, C., Gallagher, D., & Thompson, L. W. (1991). Alliance prediction beyond in-treatment symptomatic change as psychotherapy progresses. Psychotherapy Research, 1, 104–112.Google Scholar
  21. Hamilton, M. (1967). Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology, 6, 278–296.PubMedGoogle Scholar
  22. Hatcher, R. L., & Barends, A. W. (1996). Patients’ view of the alliance in psychotherapy: Exploratory factor analysis of three alliance measures. Journal of Consulting and Clinical Psychology, 64, 1326–1336.PubMedCrossRefGoogle Scholar
  23. Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the working alliance inventory. Journal of Counseling Psychology, 36, 223–233.Google Scholar
  24. Horvath, A. O., & Greenberg, L. S. (Eds.). (1994). The working alliance: Theory, research, and practice. New York: John Wiley & Sons.Google Scholar
  25. Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology, 61, 561–573.PubMedCrossRefGoogle Scholar
  26. Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in pychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 38, 139–149.Google Scholar
  27. Ilardi, S. S., & Craighead, W. E. (1994). The role of nonspecific factors in cognitive-behavior therapy for depression. Clinical Psychology: Science and Practice, 1, 138–156.CrossRefGoogle Scholar
  28. Imber, S. D., Pilkonis, P. A., Sotsky, S. M., Elkin, I., Watkins, J. T., Collins, J. F., et al. (1990). Mode-specific effects among three treatments for depression. Journal of Consulting and Clinical Psychology, 58, 352–359.PubMedCrossRefGoogle Scholar
  29. Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., et al. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295–304.PubMedCrossRefGoogle Scholar
  30. Keller, M. B., McCullough, J. P., Klein, D. N., Arnow, B., Dunner, D. L., Gelenberg, A. J., et al. (2000). A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. New England Journal of Medicine, 342, 1462–1470.PubMedCrossRefGoogle Scholar
  31. Klein, D. N., & Santiago, N. J. (2003). Dysthymia and chronic depression: Introduction, classification, risk factors, and course. Journal of Clinical Psychology/In Session, 59, 807–816.PubMedGoogle Scholar
  32. Klein, D. N., Schwartz, J. E., Santiago, N. J., Vivian, D., Vocisano, C., Castonguay, L. G., et al. (2003). The therapeutic alliance in chronic depression: Prediction of treatment response after controlling for prior change and patient characteristics. Journal of Consulting & Clinical Psychology, 71, 997–1006.CrossRefGoogle Scholar
  33. Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., et al. (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the national institute of mental health treatment of depression collaborative research program. Journal of Consulting & Clinical Psychology, 64, 532–539.CrossRefGoogle Scholar
  34. Luborsky, L., & Singer, B. (1975). Comparative studies of psychotherapies. Is it true that “everyone has one and all must have prizes”? Archives of General Psychiatry, 32, 995–1008.PubMedGoogle Scholar
  35. Manber, R., Arnow, B., Blasey, D., Vivian, D., McCullough, J. P., Blalock, J. A., et al. (2003). Patient’s therapeutic skill acquisition and response to psychotherapy, alone or in combination with medication. Psychological Medicine, 33, 693–702.PubMedCrossRefGoogle Scholar
  36. Markowitz, J. C. (1995). Comorbidity of dysthymic disorder. In D. N. Klein (Ed.), Diagnosis and treatment of chronic depression (pp. 41–57). New York: Guilford.Google Scholar
  37. Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450.PubMedCrossRefGoogle Scholar
  38. McCullough, J. P. (2000). Treatment for chronic depression: Cognitive behavioral analysis system of psychotherapy. New York: Guilford Press.Google Scholar
  39. McCullough, J. P. (2001). Skills training manual for diagnosing and treating chronic depression: Cognitive behavioral analysis system of psychotherapy. New York: Guilford Press.Google Scholar
  40. McCullough, J. P. (2003). Patient’s Manual for CBASP. New York: Guilford Press.Google Scholar
  41. Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work. New York: Oxford University Press.Google Scholar
  42. Norcross, J. C., & Goldfried, M. R. (Eds.). (2003). Handbook of psychotherapy integration. New York: Oxford University Press.Google Scholar
  43. Omer, H., & London, P. (1989). Signal and noise in psychotherapy. The role and control of non-specific factors. British Journal of Psychiatry, 155, 239–245.PubMedCrossRefGoogle Scholar
  44. Persons, J. B., & Burns, D. D. (1985). Mechanisms of action of cognitive therapy: The relative contributions of technical and interpersonal interventions. Cognitive Therapy and Research, 9, 539–551.CrossRefGoogle Scholar
  45. Rector, N. A., Zuroff, D. C., & Segal, Z. V. (1999). Cognitive change and the therapeutic alliance: The role of technical and nontechnical factors in cognitive therapy. Psychotherapy, 36, 320–328.Google Scholar
  46. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103.PubMedCrossRefGoogle Scholar
  47. Safran, J. D., & Muran, C. J. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York: Guilford Press.Google Scholar
  48. Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32, 752–760.PubMedCrossRefGoogle Scholar
  49. Stiles, W. B., Shapiro, D., & Elliott, R. (1986). Are all psychotherapies equivalent? American Psychologist, 41, 165–180.PubMedCrossRefGoogle Scholar
  50. Tracey, T. J., & Kokotovic, A. M. (1989). Factor structure of the working alliance inventory. Psychological Assessment, 1, 207–210.Google Scholar
  51. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum.Google Scholar
  52. Whisman, M. A. (1993). Mediators and moderators of change in cognitive therapy of depression. Psychological Bulletin, 114, 248–265.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media, Inc. 2006

Authors and Affiliations

  • Neil J. Santiago
    • 1
  • Daniel N. Klein
    • 1
    Email author
  • Dina Vivian
    • 1
  • Bruce A. Arnow
    • 2
  • Janice A. Blalock
    • 3
    • 12
  • James H. Kocsis
    • 4
  • John C. Markowitz
    • 4
  • Rachel Manber
    • 5
    • 13
  • Lawrence P. Riso
    • 6
  • Barbara O. Rothbaum
    • 7
  • A. John Rush
    • 8
  • Michael E. Thase
    • 9
  • James P. McCulloughJr.
    • 10
  • Martin B. Keller
    • 11
  1. 1.Department of PsychologyStony Brook UniversityStony Brook
  2. 2.Department of Psychiatry and Behavioral SciencesStanford University School of MedicineStanford
  3. 3.Department of PsychiatryUniversity of Texas Medical BranchGalveston
  4. 4.Department of PsychiatryCornell University Medical CollegeUSA
  5. 5.Department of PsychiatryUniversity of Arizona School of MedicineUSA
  6. 6.Department of PsychologyGeorgia State UniversityUSA
  7. 7.Department of PsychiatryEmory University School of MedicineUSA
  8. 8.Department of PsychiatryUniversity of Texas Southwestern Medical CenterDallas
  9. 9.Department of PsychiatryUniversity of Pittsburgh School of MedicineUSA
  10. 10.Department of PsychologyVirginia Commonwealth UniversityUSA
  11. 11.Department of Psychiatry and Human BehaviorBrown University School of MedicineProvidence
  12. 12.M. D. Anderson Cancer CenterUSA
  13. 13.Department of Psychiatry and Behavioral SciencesStanford UniversityUSA

Personalised recommendations