Group Treatment Manual for Persistent Depression

Cognitive Behavioral Analysis System of Psychotherapy (CBASP) Therapist’s Guide

Liliane Sayegh, J. Kim Penberthy

• Publisher: Routledge
• Year: 2016
• Topic: Psychology
• eBook ISBN:
  9781317405795
• Subtopic: Abnormal Psychology
• Index: Psychology

This Cognitive Behavioral Analysis System of Psychotherapy (CBASP) Group Manual is a treatment guide for mental health professionals working with persistently depressed individuals. The manual provides a clear step-by-step application of CBASP as a group treatment modality, the research findings supporting the effectiveness of this treatment, and suggested methods of assessing outcome as well as possible applications or adaptations of the treatment to different settings and disorders. This manual is accompanied by a separate workbook for patients.

P A R T	I
		INTRODUCTION

PERSISTENT DEPRESSION

Persistent or chronic depression is a serious and debilitating disease that impacts hundreds of millions of people worldwide. Persistent depression differs from acute or single-episode depression in multiple ways, including symptom profiles, hypothesized aetiologies, and effective treatment approaches. This manual is designed to teach a group format of Cognitive Behavioral Analysis System of Psychotherapy (CBASP), which is designed specifically to treat the persistently depressed patient.

DSM-5 (APA, 2013) has consolidated the DSM-IV categories of Chronic Major Depressive Disorder and Dysthymic Disorder into one category called Persistent Depressive Disorder. To be called Persistent Depressive Disorder, the depressive symptoms must be of at least two years’ duration, as previously indicated for chronic major depression. The addition of a specifier is suggested to indicate whether the Persistent Depressive Disorder is a “pure” dysthymic syndrome; a double depression, which is a major depression superimposed on dysthymia; a recurrent major depression with residual symptoms between episodes; or is a major depressive disorder lasting for two years or more without remission (APA, 2013). Major depression is the most common mental health disorder with a lifetime prevalence rate of over 16 percent (Kessler et al., 2003) and is the leading cause of disability worldwide, as well as a major contributor to the global burden of disease (World Federation for Mental Health, 2012, 2015). According to the NIMH Collaborative Depressive Study, about 20 percent of patients with major depressive disorder will develop a chronic course of the illness (Keller et al., 1984). Patients with recurrent depression are also at risk of developing a more chronic picture with each new episode of depression (Keller & Boland, 1998). DSM-5 added a severity specifier to determine the degree of functional disability in persistent depression (APA, 2013).

Numerous patients (up to 15 percent) remain very depressed after multiple interventions with aggressive pharmacological and psychotherapeutic treatments (Berlim & Turecki, 2007). Only about 20 percent to 40 percent of patients receiving their first treatment for a major depressive episode are expected to achieve a relatively asymptomatic state (Sackeim, 2001). Even then, there is often a lag until a full recovery of social and occupational functioning is achieved (Sackeim, 2001). It is common to find that patients who respond to treatment can continue to experience residual attenuated depressive symptoms as well as symptoms not usually considered among the core symptoms of depression. These symptoms may include irritability, problems with depressive thinking, and problems functioning socially and at work (Fava, Ruini, & Belaise, 2007).

Persistent depression has been found to be associated with a younger age of onset, a family history of mood disorders, co-morbid anxiety, substance abuse, and personality disorders (Hölzel, Härter, Reese, & Kriston, 2011; Kornstein & Schneider, 2001; Sonawalla & Fava, 2001; Thase, 1997; Thase, Friedman, & Howland, 2001). In addition, patients with persistent depression have more problems within the social environment (e.g. low social integration, low social support, negative social interaction) (Hölzel et al., 2011).

McCullough (2000) stresses the distinction between early-onset (depression before the age of 21) and late-onset patients (depression at or after the age of 21) that has been proposed by Akiskal et al. (1981, 1980). This distinction was substantiated by evidence that the majority (72 percent) of patients with dysthymic disorder have an early onset of symptoms. Early-onset patients also have an earlier onset of a major depressive disorder with a longer index of a major depressive episode, which suggests a more severe condition (Klein et al., 1999). McCullough describes the early-onset depressives as frequently having developmental histories characterized by psychological insults or psychological/emotional trauma or maltreatment. These patients were found to respond more effectively to psychotherapy (CBASP) with or without medication, while late-onset patients without childhood maltreatment or trauma appeared to respond better to combination treatment (medication and CBASP) (Nemeroff et al., 2003).

INTERPERSONAL CHARACTERISTICS OF THE PERSISTENTLY DEPRESSED PATIENT

CBASP is based upon an interpersonal theory of psychosocial functioning and thus understanding the role of interpersonal functioning in persistently depressed individuals is critical. As stated, early-onset persistently depressed individuals frequently present with a history of early trauma, maltreatment, abuse, or having experienced repeated psychological insults (Dube et al., 2001; Heim & Nemeroff, 2001; Kendler et al., 1995). In the CBASP model, these insults are hypothesized to lead to feelings of not being emotionally safe and not trusting others (resulting from classical or Pavlovian conditioning with a hurtful other) (McCullough, Schramm, & Penberthy, 2014) as well as social withdrawal and avoidance behaviors (resulting from operant or Skinnerian conditioning) and subsequent developmental arrest which negatively impacts social, cognitive, and emotional growth in disastrous ways (McCullough, 2000, 2006; McCullough et al., 2014). McCullough (2000) previously described what the cognitive-emotional derailment that accrues from the childhood interpersonal retreat looks like; he labeled it preoperational functioning borrowing the developmental phrase from Piaget (Piaget, 1926). The preoperational adult patient who is chronically depressed is hypothesized to function at a cognitive-emotional level resembling that of a preoperational child. Pre-causal thinking and jumping from a premise to a conclusion about reality characterize the thought processes of many persistently depressed patients. Conversing in a monologue style and not being informed by the behavior of others is another characteristic of the individual functioning at a preoperational level of thinking. Finally, pervasive ego-centricity and being unable to generate empathy with others consigns the person to a solitary existence. All areas of social endeavor for this adult can become severely limited over time and lead to the hallmark symptoms of chronic depression: helplessness and hopelessness.

The CBASP model posits that persistently depressed individuals become rigid in their interpersonal functioning. The previously mentioned preoperational level of functioning (Piaget, 1926, 1981) renders these patients unable to estimate the interpersonal consequences of their behavior, unable to critically appraise feedback, or to deduce causal relationships prospectively. Such deficits keep the chronically depressed individual perceptually disconnected from the environment, leaving the person feeling defeated, wary of interpersonal involvement, and without a sense of agency to act upon the world. According to the CBASP model, the cognitive-emotional functioning of chronically depressed individuals manifests interpersonally as both hostile detachment and excessive submissiveness along with an inability to move out of this interpersonal stance, even in response to friendly or supportive others. Unable to attach empathically to others or to assert themselves effectively, chronically depressed individuals have difficulty meeting their interpersonal needs; a deficit that purportedly maintains a cycle of primitive cognitive and interpersonal functioning and long-standing depressed mood (McCullough, 2000). Although acutely depressed individuals may also have interpersonal issues related to submissiveness and ineffectual assertiveness (Ball, Otto, Pollack, & Rosenbaum, 1994; Petty, Sachs-Ericsson, & Joiner Jr, 2004), the intersection of primitive hostility and submissiveness in the persistently depressed individual renders their interpersonal deficits even more severe and stable over time (Constantino et al., 2008).

Persistently depressed individuals tend to experience more interpersonal distress, feel less confident that they can be assertive or aggressive when needed, while they appear to be preoccupied with avoiding humiliation and conflict with others, compared to a normative sample (Locke et al., 2015). When experiencing more difficult interpersonal life events, they tend to use avoidance or emotion-focused coping strategies that enhance negative rumination over symptoms and their causes, which have been shown to increase depressive symptoms (Enns & Cox, 2005) and are associated with poorer quality of life (Kuehner & Huffziger, 2012). Indeed, the more depressed individuals tend to have less well-rounded interpersonal patterns that are associated with more submissive and interpersonally accommodating styles of relating than the less depressed individuals (Locke et al., 2015). Furthermore, the severely depressed individuals tend to feel less confident in being able to use problem-solving strategies or avoidance strategies, such as social diversion.

These interpersonal characteristics contribute to evidence that a submissive-dependent interpersonal style is associated with greater vulnerability to depression (Bornstein, 1992; Pincus & Gurtman, 1995). Individuals with persistent depression have been described as eliciting hostile or aggressive reactions from their therapists in relation to their own passive or passive-aggressive interpersonal styles (Constantino et al., 2012; Grosse Holtforth et al., 2012; Quilty, Mainland, McBride, & Bagby, 2013). These findings support Coyne’s theory that depressed individuals seek constant sympathy and attention from the environment which may become bothersome to others (Coyne, 1976). Joiner and his colleagues took Coyne’s theory one step further by measuring the reassurance-seeking behaviors of depressed individuals and found these behaviors to be positively associated with depressive symptoms and with interpersonal rejection (Joiner, Alfano, & Metalsky, 1992) and pointed out the contradictory nature of the depressive’s interpersonal patterns. On one hand the depressed person is observed seeking reassurance from others to enhance self-esteem but when this reassurance is obtained the authors point out that it clashes with the depressed person’s negative self-image. This in turn induces doubt regarding the veracity of the validation or reassurance received, thus compelling the depressive to seek negative feedback in order to restore the negative self-concept (Hames, Hagan, & Joiner, 2013).

Thus, these patients most often perceive that the causal influences in their life are beyond their personal control. They have a poor ability to use a problem-focused coping style and problems are described in a global way, resulting in feelings of hopelessness and helplessness. These patients see their depression as going on forever and as affecting their life in a pervasive and global way, which contributes to feelings of hopelessness. They have maladaptive interpersonal styles often playing out a “victim lifestyle” when interacting with others. These patients often adopt a submissive style of interacting that makes it difficult for the therapist not to assume a more dominant role (McCullough, 2000). McCullough (2000, 2006) describes this perceptual disconnect between the depressed patient and his or her interpersonal environment, such that the depressed patient’s behavior with others results in consequences that have no informing influence on the patient. He named this construct perceived functionality (McCullough, 2000, 2006; McCullough & Penberthy, 2011) and found it lacking in persistently depressed patients. Perceived functionality is defined as the ability to identify the consequences of one’s interpersonal behavior (McCullough, Lord, Conley, & Martin, 2010) and teaching this ability is a major objective of CBASP. CBASP is a therapeutic model that targets the interpersonal-social sphere of functioning and is aimed specifically at helping persistently depressed patients learn about the stimulus value they have on others and about the impact others have on them.

CBASP HISTORY

CBASP was developed by James P. McCullough, Jr. (2000, 2006) and is the only psychotherapy system specifically designed to meet the unique needs of those suffering from persistent depression. CBASP is a highly structured, skills-oriented interpersonal approach that teaches concrete approaches to help individuals overcome interpersonal problems and reach tangible and attainable life goals. CBASP was specifically formulated to meet the challenges and clinical requirements of the persistently depressed patient. In attempting to transform habitual and treatment-resistant patterns of behavior, CBASP therapists choreograph a collaborative focus on resolving current problems of living using behavioral analytic interpersonal procedures. In CBASP, patients are perceptually connected/re-connected with the interpersonal consequences of their behavior. Once the perception of a functional connection between behavior and consequences is learned, the patient is taught the behavioral skills necessary to bring about more empathically responsive/appropriate interactions in their specific interpersonal setting.

The emphasis in CBASP is on interpersonal social problem-solving. Interpersonal motives are at the core of these interpersonal behaviors and constitute the focus of therapeutic interventions in CBASP, while cognitions are important but only in as much as they lead to environmental-social consequences. Simultaneously, CBASP therapists deliberately manage transference issues (learned interpersonal expectancies) within the therapeutic relationship. These transference issues are manifestations of interpersonal motives that the therapist helps to identify and circumscribe. These learned expectancies, or interpersonal motives, have their roots in developmental histories of early life events of the patients. The way CBASP therapists manage and modify these transference issues and the way they understand and manage their own reactions to the patient’s learned expectancies, make CBASP a unique model when compared to other treatments for depressive disorders.

The objective of this treatment manual is to present an adaptation of this successful treatment model for persistent depression to a group modality with a rationale that is explained below. This manual will provide a detailed account of the content of each group session along with the corresponding theoretical explanations. This manualized Group-CBASP treatment is more cost-effective than individual psychotherapy and will hopefully facilitate further research into its effectiveness with this population of patients as well as with other patients suffering from bipolar depression, social phobia, Post-Traumatic Stress Disorder, or other disorders co-occurring with persistent depression, such as alcohol or substance-use disorders.

CBASP RESEARCH EVIDENCE

There is a growing body of evidence from across the globe examining the effectiveness of CBASP for treating persistently depressed patients. In a multicenter randomized controlled trial in the US, Keller and his colleagues (Keller et al., 2000) compared the acute (12-week) efficacy of an antidepressant medication (nefazodone) to CBASP when administered alone and in combination with CBASP. A total of 681 patients meeting criteria for the different subtypes of chronic depression, and with a baseline Hamilton Rating Scale for Depression (HRSD-24) score of at least 20, were treated with nefazodone alone (titrated to a dose of 600 mg, n=220); CBASP alone (16–20 sessions, n=216); or a combination of both, (n=226). Post-therapy remission and rates of improvement (based on HRSD-24 scores) were: nefazodone (48 percent); CBASP (48 percent); combination (73 percent) (Keller et al., 2000). This study stands out as the largest and most influential study of the effects of psychotherapy versus pharmacotherapy for persistent depression, according to two meta-analyses (Cuijpers et al., 2010; von Wolff, Hölzel, Westphal, Härter, & Kriston, 2012). The effects of combined CBASP and pharmacotherapy were demonstrated to be greater than those of combined Interpersonal Psychotherapy (IPT) and pharmacotherapy (Kriston et al., 2014; von Wolff et al., 2012). The study by Keller et al. (2000) also demonstrated significantly increased effect sizes with increased number of therapy sessions, although Cuijpers et al. (2010) was the only study to demonstrate this. Results from Cuijpers et al. (2010) suggest that at least 18 sessions are needed to show optimal effects of psychotherapy. CBASP has also been identified as a possible monotherapy for the treatment of acute persistent depression, with comparable efficacy to medication (Kriston et al., 2014). A secondary analysis of the Keller et al. (2000) data suggests that psychotherapy in the form of CBASP provides additional benefit for those with a history of early adverse life events or childhood trauma (Nemeroff et al., 2003).

In a later study comparing CBASP with supportive psychotherapy as an adjunct to pharmacotherapy in the management of treatment-resistant chronic depression (the REVAMP Trial), Kocsis et al. (2009) failed to demonstrate a difference between the therapies, or an advantage over medication alone. The REVAMP study, however, deviated significantly from the original CBASP study design in the following ways: (1) pharmacotherapy alone was administered during the acute Phase I; (2) the non and partial responders were given an “augmented” dose of psychotherapy (CBASP or Supportive Therapy) in Phase II, after medication failed; (3) the majority of subjects opted for pharmacotherapy over psychotherapy at the outset of the study; and (4) the mean number of CBASP psychotherapy sessions was fewer than 13 (Kocsis et al., 2009). There were also some significant differences in the clinical characteristics of the patients in the two studies. These key differences may help explain the failure to replicate findings from the Keller et al. (2000) study.

In a small randomized controlled trial (n=30), in a German sample, a course of CBASP (mean number sessions = 21.2) was shown to have roughly equivalent efficacy to a similar course of IPT (based on clinician rated depressive symptoms). However, remission rates (mean HRSD-24) were higher for CBASP (57 percent) compared to IPT (20 percent). Eligible patients were required to have a diagnosis of early-onset depression with a baseline HRSD of ≥16 (me...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface
• Acknowledgments
• Part I Introduction
• Part II Group-Cbasp Methodology and Procedure
• Part III Group-Cbasp Sessions
• Part IV Assessing Change In Group-Cbasp
• Appendices
• References
• Index