Early Interventions in Cognitive Behavioral Therapy for Depression: A Study Contrasting a Low-Adherent and a Highly Adherent Case

In cognitive behavioral therapy for depression, the first sessions play a crucial role in determining treatment outcome. In the first sessions, the therapist needs to form an alliance to facilitate application of the techniques; agree with the patient on problem definition, problem solution, and goals; explain the rationale; and create confidence in therapy by producing early symptom relief. This article illustrates the cognitive behavioral therapy treatment process of two depressed clients: one for whom the treatment manual was followed neatly and one for whom the therapist chose not to adhere to the manual strictly. Both had a comparable end result in terms of symptom change and alliance scores. The existing literature shows evidence for starting off with behavioral techniques, supported by assigning and reviewing homework, structuring sessions, and negotiating goals. The cases also illustrate that there are circumstances, such as urgent financial problems, in which the therapists may need to leave the treatment manual early in the therapy process, albeit temporarily. Clinical Impact Statement Question: What are the key interventions of the first sessions of CBT for depression and what is the evidence? Findings: Behavioral interventions in the first stage and staying on track of jointly formulated therapy goals in a structured manner is associated with improved results, though the two cases described show that temporary deviations from the manual are sometimes necessary. Meaning: Therapists should therefore start off CBT for depression with formulating goals collaboratively, use structured aids like homework and, in general, initiate behavioral activation. Next Steps: Future research could benefit from being directed towards the effect of structured case-conceptualizations on keeping track of the goals and thus maximizing therapy-outcome.