GROUP COGNITIVE AND CONTEXTUAL THERAPIES IN

TREATMENT OF DEPRESSION
ROBERT D. ZETTLE AND JEANETTA C . RAINS
Wichita State University

Depressed subjects (N = 31) were treated with three different group therapies:
(a) complete cognitive therapy (CCT); (b) partial cognitive therapy (PCT);
or (c) comprehensive distancing(CD). All three groups showed significant,
but equivalent, reductions in depression over 12 weeks of treatment and
2-month follow-up. However, significant reductions in dysfunctional at-
titudes obtained for CCT and PCT were not found for CD, which suggests
different underlying therapeutic processes. Comparisonswith other studies
noted no differences in the efficacy of CT as a function of treatment for-
mat, but a trend toward reduced effectiveness for group vs. individual CD.
Suggestions for further research in CT and CD are presented.
Cognitive therapy (Beck, Rush, Shaw, & Emery, 1979) increasingly is recognized
as an effective treatment for depression (Blackburn, Bishop, Glen, Whalley, & Christie,
1981; Murphy, Simons, Wetzel, & Lustman, 1984; Rush, Beck, Kovacs, & Hollon, 1977;
Teasdale, Fennell, Hibbert, & Amies, 1984). With few exceptions (Hollon & Shaw, 1979;
Rush & Watkins, 1981; Shaw, 1977), cognitive therapy has been evaluated when ap-
plied in an individual rather than a group format. One obvious advantage of group
therapy is that providing services to several clients simultaneously is a more efficient
mode of treatment delivery. However, it is unclear the degree to which efficacy of treat-
ment may be compromised in the process.
The present study had several purposes. One purpose was to evaluate further the
effcacy of cognitive therapy as a function of the format (individual vs. group) in which
it is delivered. In part this was accomplished by comparing the effectiveness of two
variants of group cognitive therapy with that reported by other researchers (e.g., Rush
et al., 1977) for individually administered cognitive therapy. Previous similar comparisons
have indicated reduced efficacy for cognitive therapy when applied in a group format
(Hollon & Shaw, 1979; Rush & Watkins, 1981).
The relative efficacy of group cognitive therapy also was assessed by comparing
it with a contextual approach, comprehensive distancing (Hayes, 1987), to treatment
of depression. A previous comparative outcome study (Zettle, 1985) suggested that com-
prehensive distancing may be more effective than cognitive therapy when administered
individually. This study thus served a second purpose in further evaluating the relative
efficacy of comprehensive distancing as an alternative therapeutic approach.
Differences between comprehensive distancing and cognitive therapy are both con-
ceptual and procedural in nature. Unlike the model upon which cognitive therapy is
based (Beck, 1967, 1976), the conceptual framework from which comprehensive distanc-
ing is derived (Hayes, 1987) views cognitive activity as exerting a controlling rather than
a causal influence over dysphoric mood and related behaviors. According to a behavioral
view (Skinner, 1953, 1969, 1974), initiating causes are limited to manipulable environmen-
tal events. Because negative thoughts cannot be manipulated directly, they cannot be
regarded as causes for both practical and conceptual reasons. This, however, is not to

This research was supported by a University Research Grant by Wichita State University. Correspondence
should be addressed to Robert D. Zettle, Department of Psychology, Wichita State University, Wichita, KS
67208.

436
Group Therapies 437

say that negative thinking therefore plays no role in the maintenance of depression. Any
impact exerted by depressive thoughts is viewed within the context of external contingen-
cies that support a controlling relationship between depressive thoughts and related affect
and behavior.
Stated somewhat differently, in everyday discourse thoughts readily are accepted
by others, and ultimately by ourselves, as legitimate “causes” or “reasons” for our ac-
tions and emotions. The primary focus from this perspective is on an analysis of the
verbal-social contingencies that give rise to the assumption that negative thoughts are
“causes” for actions and feelings (Zettle & Hayes, 1986). If these contingencies can be
weakened, the control exerted by depressive thoughts likewise should be lessened.
Due to space limitations, only a strategic overview of procedural differences be-
tween comprehensive distancing and cognitive therapy will be presented here. The in-
terested reader is advised to consult Hayes (1987) for a more detailed discussion. Most
importantly, unlike cognitive therapy, comprehensive distancing does not seek to cor-
rect unrealistic and irrational thinking through cognitive restructuring. Rather, as its
name suggests, comprehensive distancing attempts to facilitate distancing as a primary
therapeutic process. As discussed by Beck (1970), distancing is “the first, critical step”
within cognitive therapy (Hollon & Beck, 1979, p. 189), which enables clients to respond
to their negative thoughts as beliefs rather than facts. Presumably if depressed clients
are able sufficiently to “step back” from their own negative thinking, any affective and
behavioral impact associated with such self-talk should be reduced. In contrast to
cognitive therapy, the primary focus in comprehensive distancing is on altering the func-
tion of existing depressive thoughts and not on changing their form or content via
cognitive restructuring.
A final purpose of the present study was to investigate further the treatment com-
ponents that contribute most to the efficacy of cognitive therapy. Previous research (Zettle
& Hayes, 1987) indicated greater improvement for clients who were receiving a com-
plete cognitive therapy package that incorporated distancing, cognitive restructuring,
and behavioral hypothesis-testing components than those who were receiving a limited
package that combined only the latter two components. In the current investigation,
these same two packages were compared when administered in a group rather than an
individual format.

METHOD
Subjects
Volunteer female subjects were recruited through announcements in local media.
Only women were accepted as participants to ensure more homogeneous groups. A total
of 80 women presented themselves as potential subjects.
Selection Criteria
Participants were screened through a sequential, multi-criteria selection procedure
to ensure that they were experiencing a clinical level of pretreatment depression. Five
potential subjects dropped out before they had completed the screening procedure.
Beck Depression Inventory (BDI). Potential subjects first were administered the
BDI (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Acceptable subjects were re-
quired to report moderate to severe levels of depression, defined as a score of 20 or
above. Twenty individuals failed to meet this criterion.
Minnesota Multiphasic Personality Inventory (MMPI). Subjects who met criterion
on the BDI next completed the MMPI (Hathaway & McKinley, 1942). Criteria were
that they obtain a T score of 70 or greater on the Depression scale and that this score
be greater than T scores on the Psychasthenia and Hysteria scales. Six potential sub-
jects were dismissed for failure to meet these requirements.
438 Journal of Clinical Psychology, May 1989, Vol. 45, No. 3

Hamilton Rating Scale for Depression (HRSD). Subjects finally were interviewed
by an independent evaluator according to an outline suggested by Lewinsohn and his
associates (Lewinsohn, Biglan, & Zeiss, 1976). After completing each interview, the
evaluator completed the 21-item version of the HRSD (Hamilton, 1960). All interviews
were audiotaped to assess interrater reliability with a second independent evaluator. Sub-
jects were required to score 14 or above on the HRSD; 4 failed to do so.
Characteristics of Subject Sample
A total of 45 women met all selection criteria and were invited to participate in
the study; 8 declined to do so. Before they began treatment, all participants were re-
quired to verify that they were not taking antidepressant and/or tranquilizing medica-
tions. Six subjects dropped out at various points during treatment and were excluded
from further analysis. The remaining 31 subjects ranged in age from 22 to 64,with a
mean of 41.3 years. All subjects had at least a high school education, with a mean educa-
tional level of 14.1 years. A total of 25 subjects reported previous treatment for depres-
sion. Six subjects indicated previous hospitalization, and 16 subjects reported previous
pharmacotherapy. In comparison with the Rush et al. (1977) sample, no significant
differenceswere noted in the proportion of subjects with histories of previous hospitaliza-
tion, ~ ' ( 1 ,N = 49) = .047, p = ns; suicide attempts, x2(1, N = 49) = .047, p =
ns; or pharmacotherapy, ~ ' ( 1 ,N = 49) = 1.72, p = ns. There also was no difference
between the two samples in pretreatment level of depression as assessed by the BDI (t[47]
= 1.55, p = ns).
Procedure
Subjects were assigned randomly to one of three treatment conditions as follows:
complete cognitive therapy package (n = 10); partial cognitive therapy package (n =
10); and comprehensive distancing (n = 11). Two therapy groups of 4-7 members each
were conducted within each treatment condition.
All subjects completed a battery of questionnaires at pretreatment, posttreatment,
and at 2-month follow-up. At posttreatment and follow-up, subjects again were inter-
viewed by the same independent evaluator employed at pretreatment. The evaluator was
blind to each subject's treatment condition and completed the HRSD after both inter-
views. All interviews again were audiotaped and subsequently rated on the HRSD by
a second independent evaluator to obtain a measure of interrater agreement. Across
a random third of interviews, interrater agreement was both statistically significant and
adequate for research purposes (r = .89, p < .001).
Measures
In addition to the BDI and HRSD, the following measures were obtained at pretreat-
ment, posttreatment, and follow-up to assess both cognitive and behavioral processes
specific to depression.
Automatic Thoughts Questionnaire (A TQ). The ATQ is a 30-item questionnaire
designed to assess the frequency of negative thoughts associated with depression (Hollon
8z Kendall, 1980). Each thought is rated on a 5-point scale, which yields total scores
of 30-150.
Dysfunctional Attitude Scale (DAS). The DAS consists of 40 attitudes identified
by experienced clinicians as most characteristic of depression (Weissman, 1979).
Respondents indicate their agreement with each attitude on a 7-point scale, which yields
total scores of 40-280. In contrasts to the ATQ, which surveys depressive thoughts at
the level of immediate awareness, the DAS purportedly assesses depressogenic beliefs
that occur at a higher level of cognitive organization.
Pleasant Events Schedule (PES). The PES consists of 320 events rated as pleasurable
by a sample of subjects (MacPhillamy & Lewinsohn, 1972). Subjects rate the events
Group Therapies 439

for their frequency of occurrence and associated pleasantness. Three scores are derived
from the two sets of ratings: (a) Activity Level (PESAL), defined as the sum of fre-
quency ratings; (b) Reinforcement Potential (PESRP), defined as the sum of pleasant-
ness ratings; and (c) Obtained Reinforcement (PESOR), defined as the sum of the pro-
duct of frequency and pleasantness ratings for each event.
Treatment Conditions
The first author, who has had previous training in cognitive therapy and comprehen-
sive distancing, served as the primary therapist in all groups. He was assisted by the
second author, a graduate student. To assess the presence of any potential bias or other
nonspecific effects that might favor one condition over others, a questionnaire adapted
from Rose (1984) was administered at the end of each treatment session.
Each group met for 12 weekly sessions of approximately 90 minutes each. Each
subject attended at least 8 of the 12 sessions. The average number of sessions attended
within each treatment condition was as follows: complete cognitive therapy package
(1 1.2), partial cognitive therapy package (10.7), and comprehensive distancing (10.5).
All sessions were conducted according to treatment manuals, and a random third of
them were audiotaped for subsequent review as a manipulation check.’ The general for-
mat of each treatment session included reviewing assigned homework, group presenta-
tion and discussion of new treatment material, and assignment of new homework.
Complete cognitive therapy package (CCT). This treatment condition followed
guidelines outlined by Hollon and Shaw (1979) in presenting a full complement of
therapeutic procedures and strategies common to cognitive therapy (Beck et al., 1979).
Specifically, procedures that involved distancing, cognitive restructuring, and behavioral
hypothesis-testing were incorporated as part of treatment.
Distancing procedures, designed to enable subjects to regard their own negative
thoughts as beliefs to be evaluated rather than facts, included the use of similes, reat-
tribution techniques, and “alternative conceptualizations” as outlined by Beck et al.
(1979). Self-monitoring homework was assigned to identify depressive thoughts for
cognitive restructuring. Group discussion, in which turns were taken in focusing on in-
dividual group members, was used to evaluate both past and present evidence relevant
to the validity of depressive beliefs.
To help implement behavioral hypothesis-testing, the pretreatment PES was used
to identify low frequency, highly pleasurable activities. Subjects were asked to verbalize
particular thoughts that interfered with their engagement in such activities (e.g., “I
wouldn’t have a good time anyway,” “It wouldn’t turn out right,” etc.). Subjects then
were guided in designing tests of such thoughts and for homework were asked to carry
them out.
Partial cognitive therapy package (PCT). This treatment condition differed from
CCT in the absence of any distancing procedures. A comparison with CCT thus helped
evaluate the degree to which distancing constitutes a “first, critical step” within cognitive
therapy.
Comprehensive distancing (CD). This treatment condition was derived from a
behavioral view of cognitive activity and closely followed guidelines outlined by Hayes
(1987). A series of didactic and experiential exercises emphasized several major themes.
The first theme was that deliberate efforts to control or change depressive thoughts are
counterproductive in that such attempts often evoke the very thoughts to be eliminated.
A second theme was that depressive thoughts that subjects offer as reasons or explana-
tions for dysfunctional actions are themselves merely more behavior and not valid

‘Copies of the treatment manuals may be obtained from R. D. Zettle.

440 Journal of Clinical Psychology, May 1989, Vol. 45, No. 3

“causes” for such behavior. A final theme was that if subjects react to their depressive
thoughts as “behavior in context” by merely describing and identifying them, it becomes
possible for them to behave more effectively despite the continued presence of negative
thinking. To underscore this point, subjects were assigned homework that involved ac-
tivities identified from the pretreatment PES. However, rather than serving an hypothesis-
testing function as in the two cognitive therapy conditions, homework assignments were
designed to provide subjects with experience in engaging in activities while they were
having thoughts that normally would prevent them from doing so.

RESULTS
Check of Treatment Integrity
To evaluate treatment integrity (Yeaton & Sechrest, 198 l ) , audiotapes of sessions
were reviewed by two judges familiar with treatment manuals, but blind to each group’s
treatment condition. The judges were able to classify correctly 21 of 24 tapes, a propor-
tion that greatly exceeds that expected by chance, p < .001.
Nonspecific Treatment Eflects
Responses on the postsession questionnaire from each treatment session may be
viewed as a gross measure of any nonspecific, but differential treatment effects. The ques-
tionnaire consisted of several items that asked subjects to rate their own involvement
in the group and their evaluation of the session. Responses to individual questions were
combined to obtain a total score for each subject. The internal consistency of this scale
as assessed by coefficient alpha (Nunnally, 1967) was .85. Scale scores from each treat-
ment session were subjected to analysis of variance. The only significant difference among
treatment conditions occurred for session 5 , after which PCT subjects reported a more
favorable evaluation than individuals in the other two groups.
Outcome Measures
The means and standard deviations of outcome measures for each treatment con-
dition at each assessment occasion are presented in Table 1 . All measures were evaluated
with 3 (treatment condition) x 2 (assessment occasion) analyses of covariance that used
pretreatment scores as covariates. No significant main effects or interactions were noted
on the HRSD, ATQ, PESAL, and PESRP.
BDI. Analysis of covariance indicated a significant main effect for assessment oc-
casion (41,281 = 20.98, p < .001) and a marginal effect for treatment condition
(fl2,27] = 2.50, p = .lo). As seen in Table 1 , reduced levels of depression were reported
by all three conditions from pretreatment through follow-up. A comparison of adjusted
means revealed a lower score for CD (adjusted M = 8.10) than CCT (adjusted
M = 14.75) and PCT (adjusted M = 10.12).
DAS. An effect for treatment condition approached, but did not reach a traditional
level of statistical significance ( a 2 , 271 = 2.88, p = .07). An inspection of adjusted
means indicated greater endorsement of depressogenic beliefs by CD subjects (adjusted
M = 142.33) than those who were receiving CCT (adjusted M = 118.20) and PCT (ad-
justed M = 120.85). Also, as shown in Table 1 , significant reductions in DAS from
pretreatment through follow-up occurred for CCT (t[9] = 2.73, p < .05) and PCT
(t[9] = 4.19, p < .01). By contrast, reductions for CD were not significant
(t[10] = 1.21, p = ns).
PESOR. A significant treatment condition x assessment occasion interaction was
found (a2,281 = 3.30, p = .05). Adjusted means that contribute to the effect are
presented in Table 2. As indicated in Table 2, CCT and CD at least maintained treat-
ment gains from posttreatment to follow-up, whereas PCT showed deterioration.
Group Therapies 44 1

Table 1
Means and Standard Deviations of Outcome Measures

Treatment condition

CCT PCT CD
Measure M SD M SD M SD

BDI
Pre 26.90 5.42 26.20 3.91 29.27 6.17
Post 16.20 10.83 12.40 7.60 11.27 7.39
F-U 12.90 12.21 7.00 7.50 6.09 4.09
HRSD
Pre 22.30 4.83 19.30 2.63 22.82 5.71
Post 12.30 9.80 9.00 5.29 9.36 6.41
F-U 12.00 10.37 9.60 7.46 7.82 4.51
ATQ
Pre 87.30 21.09 88.80 26.12 92.54 23.25
Post 72.60 28.20 74.20 25.38 60.55 25.57
F-U 69.10 35.69 58.30 24.75 66.82 22.73
DAS
Pre 140.90 32.35 161.50 30.43 156.09 32.66
Post 127.80 37.63 123.30 27.08 141.64 44.68
F-U 119.20 25.97 124.50 25.60 145.27 36.14
PESAL
Pre .67' .I0 .69 .I2 .66 .12
Post .68 .12 .76 .14 .76 .10
F-U .70 .19 .72 .12 .75 .08
PESRP
Pre .97= .30 1.09 .30 1.08 .26
Post 1.05 .18 1.14 .23 1.16 .24
F-U 1.17 .I7 1.17 .24 1.17 .27
PESOR
Pre .808 .22 .95 .2 1 .84 .29
Post .88 .22 1.11 .28 1.04 .23
F-U .98 .27 .97 .20 1.07 .24

'Higher scores denote improvement.

Clinical Sign ipcance

The relative efficacy of treatment conditions also was evaluated by comparing the
clinical status of subjects at posttreatment and follow-up. A BDI score of 15 or lower
has been recognized as reflecting at least partial improvement (Rush et al., 1977). Using
this cut-off, the clinical status of each subject at posttreatment and follow-up was
categorized as improved or not improved. As the results in Table 3 indicate, there were
no significant differences among treatment conditions in the proportion of subjects who
442 Journal of Clinical Psychology, May 1989, VoI. 45, No. 3

showed improvement at posttreatment and follow-up. However, at follow-up, only PCT

and CD had a proportion of subjects who showed improvement which exceeded that
expected by chance.

Table 2
Adjusted PESOR Means for Treatment Conditions at Posttreatment and Follow-up

Assessment occasion

Treatment condition Posttreatment FOIIOW-UP

CCT .92' .98

PCT 1.06 .97
CD 1.05 1.07

'Higher scores denote improvement.

Table 3
Clinical Status of Subjects at Posttreatment and Follow-up

Treatment condition

Assessment occasion CCT PCT CD

Posttreatment
Improved (BDI 5 15) 7 7 7
Not improved (BDI 2 16) 3 3 4
p value .172 .172 .274
FOIIOW-UP
Improved (BDI 5 15) 7 9 11
Not improved (BDI 2 16) 3 1 0
p value .172 .011 < .001

Note. -p values are based on one-tailed binomial test.

Comparisons With Other Studies

To evaluate the effectiveness of the group approach, the results were compared with
findings from other studies in which the same treatment conditions were administered
individually. A comparison with the findings of Zettle (1985) indicated no significant
differences in BDI scores at posttreatment or follow-up for the two cognitive therapy
conditions as a function of treatment format. A comparison of group (M = 11.27) vs.
individually administered CD (M = 4.74) at posttreatment, however, found a lower
level of depression for the latter that approached statistical significance ( t [ 1 5 ] = 1.80,
p < .lo).
Results also were compared with the findings of Rush et al. (1977) for individually
administered cognitive therapy. Subjects in the present study received 12 weekly ses-
sions of treatment, whereas participants in the Rush et al. study received up to 20 ses-
sions of cognitive therapy over this same period. To equate amount of treatment, post-
treatment BDI scores from the present study were compared with BDI scores from the
Group Therapies 443

Rush et al. sample obtained at the end of session 12.* There was no significant difference
between the Rush et al. sample (M = 11.33) and the two cognitive therapy conditions
combined (M = 14-30), t(36) = 1.03, p = ns. Similarly, there also was no difference
between the Rush et al. sample and CD.
DISCUSSION
Significant, but equivalent, reductions in depression were noted for the three treat-
ment conditions. In contrast to previous research (Zettle, 1985) that suggested superiority
of comprehensive distancing over cognitive therapy when administered individually, the
present findings detected no significant differences in efficacy between the two approaches
despite a trend on the BDI that favored CD. The lack of any outcome differences ap-
pears to have resulted from diminished effectivenessfor CD when administered in a group
format. Similar findings also have been reported by Hayes (1987). Nevertheless, the
overall results do suggest that comprehensive distancing may provide an alternative ap-
proach to the treatment of depression that merits further investigation.
The possibility that comprehensive distancing represents an alternative to cognitive
therapy is underscored by differences obtained in the DAS. In view of several recent
studies (Reda, Carpiniello, Secchiaroli, & Blanco, 1985; Simons, Garfield, & Murphy,
1984; Simons, Murphy, Levine, & Wetzel, 1986) that document nontreatment-specific
reductions in depressogenic beliefs as depression is remitted, the failure to obtain signifi-
cant reductions in DAS scores for CD subjects seems especially noteworthy. At the very
least, such findings strongly suggest that CD initiates therapeutic change through a pro-
cess that differs from that of cognitive therapy.
An interpretation consistent with the conceptual framework from which it is derived
is that CD exerts its primary therapeutic influence through a behavioral instead of
cognitive process. In particular, being “caught up” in one’s own depressive thoughts
may create an insensitivity to natural contingencies that would support more adaptive
functioning. Findings from several recent human operant investigations suggest that
responding under the control of verbal stimuli, such as thoughts and beliefs, often is
insensitive to natural consequences that surround such behavior (Catania, Matthews,
& Shimoff, 1982; Hayes, Brownstein, Zettle, Rosenfarb, & Korn, 1986; Shimoff,Catania,
& Matthews, 1981). By reducing the functional control exerted by depressive cognitive
activity, comprehensive distancing may have enabled behavior to contact natural con-
tingencies that supported therapeutic change.
The lack of significant change in DAS scores for CD subjects also seems noteworthy
given suggestions that reductions in depressogenic beliefs may be predictive of long-
term maintenance of therapeutic improvement (Rush, Weissenburger, & Eaves, 1986;
Segal & Shaw, 1986; Simons et al., 1986). On this basis, it could be hypothesized that
therapeutic gains through CD would show less durability than those associated with
cognitive therapy. Additional research that incorporates a longer follow-up phase should
help determine whether the equivalence between comprehensive distancing and cognitive
therapy seen in the short run is maintained throughout a more prolonged posttreatment
period.
Although comparisons of this study’s results with those of other researchers must
be done cautiously, the efficacy of cognitive therapy appears to be unaffected by the
format in which it is administered. This tentative conclusion, however, is not consistent
with similar comparisons reported by others (Hollon & Shaw, 1979; Rush & Watkins,
1981). Further research in which group vs. individually administered cognitive therapy
are compared directly within the same study appears necessary to resolve this discrepancy.

2The authors wish to thank the Center for Cognitive Therapy for providing these data.
444 Journal of Clinical Psychology, May 1989, Vol. 45, No. 3

Regardless of whether group cognitive therapy ultimately is found to be as effec-

tive as individual treatment, further study of the therapeutic components and mechanisms
that underlie each seems warranted. Unlike earlier results that involved individually ad-
ministered cognitive therapy (Zettle & Hayes, 1987), no differences were noted between
CCT and PCT. One possibility is that the findings from one or both studies may be
unreliable. Replication should help resolve this issue. Another possibility is that the group
format may introduce processes, such as group support, cohesion, and modeling in-
fluences, that override and obscure therapeutic components and processes operative at
the individual level. Further component and process research of cognitive therapy at
both group and individual levels should not only increase our scientific understanding
of its efficacy, but, ultimately, lead to more effective treatment of depression as well.
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