CBASP as a Distinctive Treatment for Persistent Depressive Disorder

Distinctive features

James P. McCullough, Jr., Elisabeth Schramm, J. Kim Penberthy

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9780415870627
• eBook ISBN: 9781317588399
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

The Cognitive Behavioural Analysis System of Psychotherapy (CBASP) is the only psychotherapy model developed specifically for chronic depression. In the latest addition to the successful Distinctive Features series, the developer of CBASP, James P. McCullough Jr., along with Elisabeth Schramm and J. Kim Penberthy, provides an accessible introduction to this approach, showing how it differs from other cognitive behavioural approaches, and highlighting those features – both theoretical and practical – that make it unique.

The unparalleled problems of the chronically depressed patient are some of the most difficult that practitioners face. The disorder has usually continued for a decade or more and patients enter psychotherapy interpersonally withdrawn, detached and with little or no motivation to change. CBASP as A Distinctive Treatment for Persistent Depressive Disorder provides a new look into the phenomenological world of the patient and shows the reader why the world-view of the patient is a valid perception of reality.

CBASP is designed to address the problems of the patient in a step-by-step manner. This book explores the therapist role and shows how the CBASP model enables therapists to address the patient's depression in a zone of interpersonal safety. Patients are taught how to behave in an interpersonally facilitative manner and shown how everything they do has consequences for others (including the therapist) and on the social environment in which they live. CBASP as A Distinctive Treatment for Persistent Depressive Disorder will be essential reading for novice and experienced CBT therapists, counselors and psychotherapists treating chronic depression.

Part 1

DISTINCTIVE THEORETICAL FEATURES OF THE CBASP MODEL

1

Distinctive history of CBASP

Early beginnings

The cognitive behavioral analysis system of psychotherapy (CBASP: McCullough, 1980, 1984) is the only psychotherapy model developed specifically to treat persistent depressive disorder (APA, 2013). CBASP’s development paralleled somewhat the emergence of chronic depression as a distinctive diagnostic category in Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (APA, 1980), DSM-III-R (APA, 1987), and DSM-IV-TR (APA, 2000). There was no specific category for a chronic depressive disorder that could be reliably diagnosed until dysthymia appeared in DSM-III. Prior to DSM-III, Weissman and Klerman (1979) wrote that patients who were chronically depressed were insufficiently recognized and inadequately treated and were frequently referred to as “crocks” (Lipsitt, 1970).

In 1974, one of my (JPM) doctoral students, William F. Doverspike, and I began constructing a therapy program to treat patients who were chronically depressed (Doverspike, 1976, 1979; McCullough, 1980). These individuals were extremely egocentric, talked in a helpless and hopeless manner complaining endlessly about their mistreatment. They were inept when it came to interpersonal relationships and skills. In addition, most of them reported growing up in maltreatment family milieus rife with verbal, emotional, physical, and sexual abuse.

In 1974, Doverspike named our treatment model the cognitive behavioral analysis system of psychotherapy. The name described the model’s primary goal which was to analyze problematical areas of functioning using actual examples of situations and then remediate the deficits. CBASP also evolved concomitantly with Beckian cognitive therapy (CT) or CBT (Beck et al., 1979). Although the name sounded similar to CT/CBT, CBASP never relied on the psychopathological or treatment assumptions of CT/CBT. Chronic depression was never conceptualized as a “thinking disorder” (Beck, 1963, 1964); rather, the disorder was conceptualized as a severe mood condition resulting from an abusive developmental history. The etiological hypothesis was and still is that maltreatment experiences result in a “derailment” in social-interpersonal maturational growth. This conclusion was drawn because the adult patients functioned interpersonally in ways that mimicked the behavior of pre-operational elementary-age children. Verbalization patterns of patients were often primitive and pre-causal in nature as they moved from a hypothesis to a conclusion with no logical evaluation in between. When patients described their experiences, their language suggested they were perceptually disconnected from the social-interpersonal world they lived in; that is, what others said or did had no informing effect on their behavior. Confronting this perceptual dilemma, CBASP was designed to perceptually connect patients to the interpersonal-social world so that they would become accessible to corrective interpersonal feedback. CBASP, since its inception, rests on an interpersonal reciprocal causal determinant model of behavior (Bandura, 1977; Kiesler, 1996). Its primary goal is to teach a social-environmentally disconnected patient how to function in a reciprocal deterministic manner.

Digressing for a moment, we admit that the name, cognitive behavior analysis system of psychotherapy or CBASP (Doverspike, 1976, 1979; McCullough, 1980), may be a misleading label. People hear the name and frequently consider CBASP to be a variant of CT/CBT. Comparing CBASP with CT, several differences are noted: (1) CBASP was developed specifically to treat the chronically depressed patient while CT/CBT was originally proposed to treat acute/episodic major depressive disorder (Beck et al., 1979); (2) CBASP conceptualizes the psychopathology of the chronic patient as an essential mood disorder; (3) as noted above, CBASP is an interpersonal model (McCullough, 2006, 2012b) with the first goal being to focus patients’ attention on the therapist in order to teach them how to interact with the clinician; on the other hand, CT/CBT is primarily an intrapersonal model where the therapist’s primary focus remains on the patient’s own thinking (Beck et al., 1979; Beck, 1995, 2005); (4) expanding on this third difference, the role of the CBASP clinician is one in which a disciplined personal involvement role (McCullough, 2006) is actualized. The clinician is an active interpersonal player who teaches patients how to behave interpersonally; conversely, CT/CBT practitioners remain within the more traditional role wherein one does not disclose personal contingent reactions to patients (Beck, 1995, 2005; Whisman, 2008); and (5) finally, CBASP is a fully operationalized system emphasizing patient learning acquisition. Individuals are expected to learn and perform the “subject-matter” or goal behaviors of therapy. Patients learn to perform to criterion the exercise goals (McCullough et al., 2010; McCullough et al., 2011). There is evidence available that patients who learn the most about what CBASP teaches achieve the best therapy outcomes (Manber et al., 2003).

During the mid-1970s, the CBASP model consisted primarily of the situational analysis (SA) technique. SA is a remedial strategy that progressively connects individuals perceptually to the interpersonal environment by making explicit the consequences of their behavior. Learning to pinpoint the effects of one’s behavior is an achievement CBASP labels perceived functionality (McCullough, 2000, 2006). The acquisition of perceived functionality is the major goal of SA technique (McCullough, 2000; McCullough et al., 2010).

Continued CBASP model development and DSM diagnostic differentiation

A CBASP patient manual was developed during the mid-1980s (Kasnetz, 1986; Kasnetz and McCullough, 1983). Kasnetz’s manual became the forerunner of the current Patient’s Manual for CBASP (McCullough, 2003). Subsequently, several CBASP treatment papers (McCullough, 1980, 1984, 1991, 2001) describing the treatment of dysthymic patients with CBASP followed the publication of DSM-III (APA, 1980).

Another clinical student, Karen F. Carr (1989), employed CBASP in her cases during the 1980s investigating thinking patterns among dysthymic subjects. Kasnetz (1986) studied the interpersonal impacts of depressive behavior, while Bryan West administered CBASP to treat lung carcinoma cancer patients some of whom were chronically depressed.

During the 1980s and early-1990s, the CBASP Research Team at Virginia Commonwealth University initiated a series of studies monitoring the naturalistic diagnostic profiles of community-recruited chronic depressive subjects who remained untreated over extended time periods (Kaye et al., 1994; McCullough, 1988; McCullough et al., 1988, 1990a,b, 1994). We reported < 10 percent spontaneous remission rates during one-year periods. When the remitters were subsequently followed for 4 years, 50 percent reported recurrence of the chronic disorder. This program culminated in a review article published in 1996 (McCullough et al., 1996). Summarily, the history of the evolution of the chronic depression nomenclature and the field’s growing acceptance of the distinction between acute-episodic major depression and chronic depression enhanced the relevance of the CBASP as a model to treat chronic depression. Finally, two articles (McCullough et al., 2000, 2003) reviewing the diagnostic work from two large national clinical trials sought to determine if valid differences existed between several existing subtypes of chronic depression (i.e., double depression, chronic major depression, and recurrent major depression without inter-episode full recovery). The subtypes were compared across a wide array of measures. These analyses (n = 1,316 chronic outpatients) found only negligible differences between the subtypes. The general conclusion was that the variegated forms of chronicity, as long as the disorder lasted 2 years, could simply be labeled, chronic depression. Our proposal came to fruition in the new nomenclature addition to the unipolar diagnostic category in DSM-5 (APA, 2013) and, as noted above, chronic depression is now labeled persistent depressive disorder (dysthymia).

In 1994, CBASP was tested with a new medication, Nefazodone, in a large randomized clinical trial at 12 sites (n = 681 outpatients). The outcome of the acute phase produced the highest response rates achieved to date in a chronic depression study (Keller et al., 2000). In the ITT analysis, when CBASP was combined with drug, 77 percent of the outpatients responded to treatment. In the secondary analysis evaluating response rates among patients who completed the acute phase, the response rate was 85 percent. Notably, when CBASP patients who continued to see their CBASP therapist once-per-month were followed for 12 months during the maintenance phase, the survival rate using Kaplan–Meier survival curves revealed an 89 percent survival rate (Klein et al., 2004). Another study using this sample (Nemeroff et al., 2003) reported a superior treatment response among CBASP treated trauma patients when they were compared with a cohort receiving medication-only and who reported trauma prior to age 16.

Following the Keller et al. study (2000), McCullough (2000, 2001, 2003, 2006) wrote a series of books describing and illustrating the techniques of CBASP and proposing a diagnostic course graphing methodology to differentiate chronic depression from the acute-episodic major depressions (McCullough, 2001; McCullough et al., 1996). During the late 1990s and early 2000s, a novel therapist role was added to the CBASP model. The role was labeled disciplined personal involvement (DPI: McCullough, 2006). DPI was developed to counter the abusive developmental histories of many early-onset patients who presented formidable interpersonal barriers including basic interpersonal distrust and a lack of felt safety with interpersonal encounter.

Treatment studies with chronic patients continue to be published (e.g., McCullough, 2008, 2010; McCullough and Penberthy, 2011). CBASP randomized clinical trials have been conducted in Germany (e.g., Schramm et al., 2011), the Netherlands (e.g., Wiersma et al., 2008), and in the United Kingdom (e.g., Swan et al. 2014). Finally, CBASP has been administered successfully to two early-onset female chronically depressed adolescents (DiSalvo and McCullough, 2002; McCullough, 2012c), three chronically depressed patients with comorbid alcohol dependence (Penberthy, 2012), and one chronically depressed 42-year-old male comorbid with cued panic-disorder (McCullough, 2012d). CBASP has also been adapted for group intervention (e.g., Sayegh et al., 2012) and as an inpatient program (Brakemeier et al., 2011).

Some 34 years after the CBASP model was introduced to the clinical literature (McCullough, 1980), the treatment outreach of CBASP has expanded its scope from its original focus on persistent depressive disorder (APA, 2013) to other disorders (Belz et al., 2012). Examples of the widening scope of CBASP research and development is seen in studies examining developmental foundations, early traumatization, neurobiological and interpersonal issues, diagnostic concerns, PTSD, comorbid substance abuse, suicidality, inpatient treatment, and group administration of CBASP therapy and training (McCullough, 2012a).

Following this abbreviated history of the CBASP model, we will describe CBASP’s theoretical foundations.

2

Distinctive terminology of the CBASP model

Cognitive behavioral analysis system of psychotherapy (CBASP) uses a terminology that may be unfamiliar to many readers. To facilitate understanding of the text, brief definitions of some of the basic terminology are provided. Most of the terms below will be further elaborated in later sections. CBASP is a theoretical system of treatment that is fully operationalized in acquisition learning-performance terms. If clinicians wish, they may administer the model as a psychological experiment and empirically assess its efficacy. An operational definition of the treatment methodology is provided in Part 2; or, therapists may simply use the model as a method to treat chronic depression. However, we do encourage all therapists to administer several basic psychological instruments (“temperature reads”) to determine if treatment is working.

Persistent depression disorder (chronic depression)

The diagnostic definition for chronic depression is based on the DSM-5 (APA, 2013, p. 168) symptom checklist criteria. A diagnosis of DSM-5 persistent depressive disorder (PDD) means the disorder has persisted for ≥ 2 years with no more than an 8 weeks hiatus of no depressive symptoms. DSM-5 PDD includes specifiers such as pure dysthymic disorder, persistent major depressive (MD) episode, PDD with intermittent MD episodes with current episode, and PDD with intermittent MD episode without current episode.

Acquisition learning of the patient

CBASP is a performance-operationalized model that qualifies it to be a “psychological experiment”; that is, the major techniques, situational analysis (SA) and the interpersonal discrimination exercise (IDE), have been operationalized in performance terminology in order to assess the degree to which the SA and the IDE “subject matter” have been learned. In SA, patients learn to identify the consequences of their behavior (perceived functionality) and the IDE will generate felt safety as patients learn to discriminate successfully between the clinician and malevolent significant others (SOs). The learning data used in this way are employed to assess the possible “empirical dependence” between the amount of patient learning and the outcome variables of treatment. When the treatment data are used to test a dependence relationship between learning and the outcome, the requirements for a psychological experiment will have been met.

Disciplined personal involvement

One distinctive feature of the CBASP therapist role is disciplined personal involvement (DPI) (McCullough, 2006). DPI runs counter to a universal proscription (Freud, 1963; Rogers, 1951) for therapists lasting well over a century; this proscription is, Don’t become personally involved with your patients! In CBASP, clinicians become personally involved with patients in highly disciplined ways (tailored to the needs of persistently depressed patients) and use counter-transference reactions to modify patient behavior. DPI reactions denote an “objective” type of countertransference (Winnicott, 1949) and involve interpersonal impact reactions to verbal and nonverbal patient behaviors—that is, personal reactions to what patients are doing and saying (Kiesler, 1988, 1996; Kiesler and Schmidt, 1993). CBASP personal involvement reactions do not include “subjective” transference reactions (Spotnitz, 1969) which are the irrational and defensive reactions that reflect the needs therapists experience with particular patients. DPI was developed to counter the fallout from the extreme emotional and physical abuse and neglect which chronic patients bring to treatment. We’ve found that verbal and non-verbal expressions of acceptance, understanding, empathy, and disputation are frequently not sufficient to break into the closed PDD intrapersonal ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword—John Swan
• Preface
• PART 1 DISTINCTIVE THEORETICAL FEATURES OF THE CBASP MODEL
• PART 2 THE PRACTICAL/CLINICAL FEATURES OF CBASP
• References
• Index