Combining Guided Dialog with Cognitive Therapy for Depressed Women: Six Single-Case Studies
Randall, Elizabeth J., Thyer, Bruce A., Journal of Cognitive Psychotherapy
Cognitive therapy (CT) alone was compared to CT, plus a communication skills and relationship repair intervention called Guided Dialog (GD), in the treatment of six depressed women. Outcomes measures were the Beck Depression Inventory and the Miller Social Intimacy Scale, repeatedly administered over time in the context of single-subject research designs. Three women received CT alone, and three received CT followed by CT plus GD. Results indicated that all patients recovered from depression; however, patients who received the combined form of treatment registered greater improvements in intimacy than did clients who received cognitive therapy alone. While tentative, these results suggest that the combination of a relationally based form of treatment such as Guided Dialog, together with cognitive therapy, may warrant a more formal randomized trial.
A significant body of empirical evidence supports the association between lack of emotional intimacy and depression for women. In an early study by Brown and Harris (1978) on the social origins of depression, it was found that the lack of an intimate, confiding relationship with a primary significant other was the most important risk factor in the year preceding onset of depression in women. This study has been replicated in more or less detail at least eight times (Brown & Prudo, 1981; Brown, Andrews, Harris, Adler, & Bridge, 1986; Brugha, Bebbington, MacCarthy, Sturt, Wykes, & Potter, 1990; Campbell, Cope, & Teasdale, 1983; Lora & Fava, 1992; Martin, Brown, Goldberg, & Brockington, 1989; Parry & Shapiro, 1986 Paykel, Emms, Fletcher, & Rassaby, 1980).
Numerous superficial relationships have not been found to have a protective effect against depression for women (Miller & Lefcourt, 1982), but at least one intimate, confiding relationship with a partner or significant other can be a buffer against depression, even in the presence of severe life events (Brown & Harris, 1989). A lack of emotional intimacy in the patient's interpersonal world is also more highly correlated with relapse than any other psychosocial variable, including gender, marital status, and socioeconomic status (Belsher & Costello, 1988).
Cognitive therapy, widely recognized as a state-of-the-art individual therapy for depression, is unquestionably effective. Dobson (1989) conducted a meta-analysis of eight studies comparing cognitive therapy versus tricyclics, and found a mean differential effect size of -0.53, with a range of 0.42 to -1.74, based on Cohen's d statistic, where more negative values indicate greater superiority for cognitive therapy. A number of other studies have also demonstrated the effectiveness of cognitive therapy of depression (Beck, Hollon, Young, Bedrosian, & Budenz, 1985; Blackburn, Bishop, Glen, Whalley, & Christie, 1981; Gallagher & Thompson; 1982; Murphy, Simons, Wetzel, & Lustman, 1984).
However, cognitive therapy has been criticized by relational theorists on grounds that the model is insufficiently sensitive to the interpersonal context of depression, particularly for women, who are seen as having a more relationally based view of the world (Jack, 1991). Also problematic, in view of the association between impaired intimacy and depression, is the deemphasis within cognitive therapy on the inclusion of significant others in treatment. One of the standard texts on cognitive therapy contains two paragraphs on the recommended role of significant others in treatment, primarily for purposes of gathering information (Beck, Rush, Shaw, & Emery, 1979). At least three well regarded reference books contain chapters on cognitive therapy which make no mention of bringing significant others into session (Kovacs & Beck, 1986; Newman & Beck, 1990; Sacco & Beck, 1985). This deemphasis on dyadic work leads to the possibility that coping with lack of intimacy could be substituted for improving relationships, a potential limitation to the scope of the cognitive model. …