Putting the “cognitive” back in cognitive therapy: Sustained cognitive change as a mediator of in-session insights and depressive symptom improvement.

Objective: Although cognitive change has long been posited to drive symptom improvements in cognitive therapy (CT) of depression, whether it does so remains controversial. Methodological challenges have contributed heavily to the lack of resolution on this issue. Using a patient-reported measure of cognitive change, we tested the role of cognitive change in contributing to symptom change in CT. In addition, we tested whether therapists’ use of cognitive methods intended to promote cognitive changes predicted these changes. We also tested the specificity of the relation of cognitive methods and cognitive change by examining other psychotherapy process variables. Method: In a sample of 126 patients who participated in CT of depression, patients rated immediate cognitive change (CC-Immediate) at the end of each session and sustained cognitive change (CC-Sustained) at the start of each subsequent session. Observers rated therapist adherence and alliance for the first five sessions. Depressive symptoms were assessed at each session. For all predictors, we disaggregated within- and between-patient effects. Results: Focusing on within-patient predictors, CC-Sustained mediated the relation of CC-Immediate and subsequent symptom change. In addition, both CC-Immediate and CC-Sustained predicted symptom change. Therapist adherence to cognitive methods was the only within-patient variable to predict CC-Immediate. Conclusions: These findings are consistent with the view that cognitive change contributes to symptom reductions in CT, and that therapists’ use of cognitive methods contributes to cognitive changes during sessions. (PsycINFO Database Record (c) 2019 APA, all rights reserved)