Psychotherapy has become the modern equivalent of religion in its ability to listen to the problems of the population and provide answers on how to live fulfilling lives. The difference is that the practice of psychology is also a scientific and evolving process, striving to improve the quality of the professional services provided and effectively apply research to the treatment of specific conditions within a clinical setting. However, the difficulty lies in attempting to identify, using methods of empirical investigation, exactly which components of therapy contribute to long-standing change in a clients' condition. With the high incidence of depression in Australia today (particularly among adolescent males) it is important to establish not only an understanding of the symptomatology of depression as an illness, but improve the efficacy of the psychotherapeutic session in treating depressogenic cognitions and behaviour.

The cognitive model of depression (Beck, 1967, 1987; Beck, Rush, Shaw, & Emery, 1979) states that depressed individuals have learned cognitve schemas (also referred to as assumptions or core beliefs) that predispose them toward negative interpretations of life events which in turn effect their functioning as they then engage in depressive behaviour. Cognitive-behavioural therapy (referred to as either CBT or alternatively CT) for depression includes interventions that focus on the automatic thoughts (cognitive distortions) of the depressed individual, their observable behaviour and underlying cognitive schemas which lead to depressive thinking. The therapists task is to change overt behaviour, teach the client to assess and possibly correct distortions in thinking, and finally move towards the identification and modification of deeper, more stabile schemas and cognitive structures.

Numerous studies have been performed which document the clinical effectiveness of CBT in managing depression. Meta-analyses such as that conducted by Dobson (1989), using 28 studies employing a common outcome measure (Beck Depression Index; BDI), praise CBT as being either as powerful or more effective than pharmacotherapy, behaviour therapy, interpersonal therapy and other psychotherapies or waiting-list control conditions. While occasionally others contest such findings (Hollon, Shelton, & Loosen, 1991; Elkin, Shea, Watkins, Imber, Stotsky, Collins, Glass, Pilkonis, Leber, Docherty, Fiester, & Parloff, 1989) it seems that CBT has almost become one of the most popularly researched forms of therapy in the treatment of depressive symptoms. The most interesting studies (of particular relevance when trying to determine which components of therapy contribute to long term change in the client) are those which attempt to analyse which constituents of CBT contribute most to the final result. One such study was performed by Jacobson and his associates (1996) to experimentally test explanations of CBT's efficacy drawn from the work of Beck, Rush, Shaw and Emery (1979).

Jacobson and his colleagues (1996) were interested in testing two hypotheses which they identified as the "activation hypothesis" and the "coping skills" hypothesis. The activation hypothesis refers to CBT's aim to instigate clients to become active again, thereby putting them in contact with available sources of reinforcement. This instigation usually plays a major role in the early stages of CBT, and may be why most change during CBT occurs within the first few weeks of its application (Rush, Beck, Kovacs, & Hollon, 1977). The coping skills hypothesis refers to the client learning to cope with depressing events and depressogenic thinking so that they may more effectively deal with life stress and the automatic thoughts associated with these events.

Jacobson and his associates (1996) are employing these two hypotheses as a method of identifying if therapies which utilize these components may be just as effective as CBT, which employs one final stage of treatment: the identification and change in core schema and cognitive structures. If this last component is indeed a valid part of the therapeutic process, CBT should perform better than therapies employing behavioural activation alone, or therapies employing both behavioural activation and the teaching of coping skills for automatic thoughts. Jacobson et al. (1996) found no evidence, however, that the complete implimentation of the full process of CBT provided any better outcome than the behavioural activation or combined behavioural activation and automatic thought treatments. We are therefore left in something of a quandary, as this would suggest that a deeper and more thorough therapeutic exchange in which the nature of underlying schema and cognitions are exposed and altered may not be a contributing factor to CBT's success. So what is it that produces the long term change not only in CBT but in the context of specific applied therapies within a series of treatment sessions?

While a great deal of research exists promoting particular therapies and their effectiveness within the context of dealing with particular problems, there exists a difficulty in determining and demonstrating differential effects amongst the specific therapies in the treatment of depression (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961; Elkin, et al.,1989; Elliott, Clark, Wexter, Kemeny, Brinkerhoff, & Mack, 1990). Part of this difficulty may be attributable to a researcher's allegiance to a particular psychotherapy. Gaffan, Tsaousis and Kemp-Wheeler (1995) point out that the apparent success of CBT as a therapy for depression may be the result of openly positive meta-analyses, such as that conducted by the aforementioned Dobson (1989), in fact being examples of a researcher's allegiance to that particular therapy. This phenomena has been noted not only in respect to Dobson's (1989) unequivocal support for CBT, but numerous other meta-analyses of psychotherapies (eg. Berman, Miller, & Massman, 1985; Smith, Glass, & Miller, 1980) in which the outcome of the research and the researcher's preference for that therapy were associated (Robinson, Berman, & Neimeyer, 1990).

However, CBT still reamins the most popular method for treating depression, and significant research into the applicability of therapies in terms of a practical therapeutic alliance usually focuses on CBT. Therapeutic alliance being one of the significant components of therapy contributing to long term change apart from the specific therapy being employed. Therapeutic alliance is defined as the attachment and collaboration between a client and therapist (Bordin, 1979), and is usually credited to psychoanalytic theorists, who emphasized the formation of a cooperative "working alliance" in which the patient works with a therapist's interpretations (Greenson, 1965; Sterba, 1934).

As mentioned above, Jacobson and his colleagues (1996) identified behavioural activation and the teaching of coping skills as being significant components of CBT (although not exclusively). Similarly, Castonguay and her associates (1996) performed an analysis of the therapists focus on the clients intrapersonal functioning as a determinant in the therapy's overall efficacy. Intrapersonal functioning not only involves the client's experiences outside therapy (behavioural activation) and their ability to excercise learned coping skills, but more importantly the therapeutic alliance as a significant determinant of the therapeutic outcome. While focusing on CBT, Castonguay et al. (1996) point out that the alliance of therapist and client is a common contributor to many psychotherapy outcomes. This echoes the findings of Goldfried and Padawer (1982) who suggest that therapeutic alliance is an important ingredient of change in psychodynamic, humanistic, and cognitive-behavioural treatments. In their own study, Castonguay and her companions (1996) found that the therapeutic alliance and clients' emotional experiencing, common to different psychotherapeutic approaches, were both related to an improvement in the cognitive therapy patient. While the exact mechanism of change remains speculative, especially in respect to the role of emotional experiencing (Teasdale, 1993; Greenberg & Safran, 1987), these findings are an extension of Safran and Wallner's (1991) investigation of cognitive therapy which emphasized the therapeutic relationship within the context of this particular kind of therapy, as rated using a transtheoretical measure of alliance.

A relatively recent study of particular merit by Raue, Goldfried and Barkham (1997) also utilized the transtheoretical measure of alliance used by Safran and Wallner (1991): the Working Alliance Inventory (WAI; Horvath, 1982). The WAI was employed in order to gain a rating of the alliance between the therapist and client, and then examine the determinants for a high rating. Raue, Goldfried and Barkham (1997) found that CBT was rated higher than other forms of therapy, a finding consistent with an earlier study by Raue, Castonguay and Goldfried (1993) who compared CBT with psychodynamic therapy sessions. However, it seems naive to assume that the application of a particular theory is the sole contributing factor to client/therapist ratings of therapeutic alliance. In fact, studies such as Marmar, Gaston, Gallagher and Thompson (1989) and Brunink and Schroeder (1979) revealed different results in terms of which therapy was more effective, a finding which may have lead Raue, Goldfried and Barkham (1997) to try and identify what other factors may have produced the high ratings for particular therapy sessions besides the specific form of therapy being employed.

Two additional factors were empirically investigated using clinically diagnosed outpatients suffering from depression (using the Beck Depression Inventory): a) the possibility that high-impact sessions may significantly differ from low-impact sessions, and b) both therapist evaluations of session-depth and smoothness-comfort, and client ratings of affective state using the Session Evaluation Questionnaire (SEQ; Stiles, 1980) contributed to the subsequent WAI rating of therapist-client alliance. It was found that those sessions identified as being of 'high-impact' were often characterized by high WAI scores and, not surprisingly, sessions receiving a high rating of client-patient alliance were positively related to therapist ratings of session depth and smoothness and to client ratings of mood.

The working alliance of the therapist and client is without a doubt one of the most important facets of the therapeutic session. For regradless of the efficacy of any one particular therapy in being particularly outstanding in the treatment of depression, it cannot be practically implemented if no alliance is formed within the actual therapy session. This is why the earlier finding by Jacobson et al. (1996) seems so particularly unsettling. If it is true that the particular therapy being employed is not necessarily relevant to the final outcome of therapy, either because there is no statistically definitive evidence for the superior efficacy of therapies such as CBT, or studies have been performed by researchers showing a particular allegiance to that therapy, we have to ask whether it is the alliance created between therapist and client that truly determines the long-term outcome. However, in the case of CBT for depression, Jacobson and his colleagues found that the aspect of CBT that distinguishes it from therapies dealing specifically with behavioural activation and/or coping skills, that is, its probing into the underlying schemas and cognitions, was not particularly relevant to its efficacy. It would seem that a 'deep' probing of the clients beliefs would be one of the true tests of the therapeutic alliance, and would therefore contribute to the overall result of the CBT session. Indeed, as reported, Raue, Goldfried and Barkham (1997) found sessions that are judged to be of high-impact, as well as sessions rated by therapists to be smooth and deep, and by clients to be significant in terms of mood, were correlated with high ratings of therapeutic alliance using the WAI. It would therefore seem logical to assume that CBT's success is reliant upon it's ability to form a deep, significant bond betwen therapist and client. Otherwise, we might conclude that what empirical studies are looking for is an immediate change in the appearance of depressive symptoms, rather than any long term change in the client's beliefs and underlying schema.

Whatever the conjecture on the superiority of CBT as a means of treating depression, it remains one of the most thoroughly researched and well documented methods to be employed within the therapeutic context. However, it seems difficult to make decisions about it's efficacy when there exist conflicting messages on what actually distinguishes it as one of the most popular methds of psychotherapy for depression. The outstanding fact seems to be that the formation of a therapeutic rapport, what the psychoanalysts would term a "working alliance", is in fact the only significant determinant of a therapy's success in producing not only effective change in depresive symptoms within the clinical and outpatient settings, but significant long-term change in the client's world.

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