Problem mastery and motivational clarification as mechanisms of change in cognitive-behavioral therapy for depression: Secondary analysis of a randomized controlled trial.

OBJECTIVE In process-outcome research, there is a growing body of literature investigating the therapeutic mechanisms underlying the promotion of positive change. This study investigated the between- and within-patient effects of problem mastery and motivational clarification on outcome in patients receiving two variations of cognitive therapies for depression. METHODS This study drew on data of a randomized controlled trial conducted at an outpatient clinic and included 140 patients randomly assigned to 22 sessions of either cognitive-behavioral therapy or exposure-based cognitive therapy. To address the nested structure of the data and analyze mechanism effects, we used multilevel dynamic structural equations models. RESULTS We found significant within-patient effects of both problem mastery and motivational clarification on subsequent outcome. CONCLUSION The results suggest that changes in problem mastery and motivational clarification precede symptom improvement during cognitive therapy for depressed patients and thus there may be benefit in fostering these putative mechanisms during psychotherapy