rambling 19

I don’t know what the RMV (registry of Motor Vehicles) has against me but I still have not been able to renew my license and it is going to expire tomorrow, my birthday. Which I am not having a cake or any celebration because my family and I are sick. I can’t even leave my room without dizziness so I guess it’s kind of a good thing.

It is so different typing on my old laptop than my new one. But with using this old one I still was able to get the pre form for my license. I just hope that the place is open on Monday and I am feeling better to knock some heads in.

I still haven’t finished Christmas shopping but I don’t care. I’m too sick to finish. I have to get a photo album for my dad and some gift card for my niece. I’ll probably do that Monday as well.

Looks like the Chinese food that I ordered online didn’t go through. No matter as I have no appetite anymore anyways. I am hungry but I just don’t know what to eat. I’m tired of just eating soup.

I haven’t left my room except to shower. That is all I have done today. I don’t know what the weather is like. People have been talking about the world ending. I knew it was a hoax. It is the start of the new calendar which is what I have been saying all along.

why the stigma in preventing suicide?

People always scramble when there is lightening but not for suicide prevention. Lightening takes less lives each year than suicide does. I think people don’t scramble because there still is this stigma that it won’t happen. People don’t want to acknowledge that suicide exists and if it doesn’t exist, why prevent it? The stigma is that you run into the old “every man has a choice”. People believe that suicidal people are just going to do it anyway so why bother preventing the inevitable. It happens to those that see it in the ER. Most people cannot fathom why someone would want to take their own life. They think life is so grand that nobody would want to take it. They believe in this bubble that if it doesn’t happen to me, it doesn’t happen at all. I have a cousin who thinks this way. She thinks that if she doesn’t pay attention to the bad stuff, maybe it won’t happen as often. She just wants to be happy all the time. There is nothing wrong with that but not acknowledging serious mental illness is a problem. They have to believe that there is always good things in their world for their sanity. Thomas Joiner, a psychologist that deals with suicidality believes that most suicide prevention would cost less if people actually believed it exists. In his book why people die by suicide, he proposes the risk of a bicyclist getting hit by a car over the prevention barrier of the SF bridge. More people die by suicide (30 per year) than someone dying by getting hit while riding a bicycle.

I think I understand why people are afraid. They still have it in their mind that suicide should not be talked about. If it is talked about then it is real. And if it is real, then something should be done to prevent it.  Unfortunately, not enough people think that suicide is real despite it climbing and it being in the top 10th percentile in the U.S.

my CES story, first time

I started having back trouble when I was twenty-three.  It was the summer of 1999 and my nephew and I loved to wrestle. His biggest thrill was body-slams on the couch.  He was five at the time.  He was getting a bit heavy as he was a growing boy and I thought I could still handle him.  My back thought otherwise.  I must have thrown the body slam a different way and hurt my back.  After a week and still not getting better, I called my doc for a muscle relaxer and the morons (her office staff) told me I had to be seen first (which was about a week after I called for the script).  After my doctor performed the straight leg lift, I was in agony the next day as I woke up with severe sciatica.  The pain was going through my buttock down my leg.  I called the on-call doc as it was the weekend and was told to go to the walk-in unit.  There was about a three-hour wait.  My godfather was in the hospital at this time so I went up and visited him while I was waiting.  At the end of the three hours, I was in such agony; I couldn’t walk more than a foot apart.  The doctor at the walk-in unit told me that because I was in so much pain, he wanted to run some tests.  I then waited another hour in the ER (they wanted to do a CT (least that was why I thought they transferred me there) as I refused an MRI (I am claustrophobic)), got tired and bullshit as I was in the minor area and people who HAVEN’T been seen by a doctor, are getting taken in and x-rayed. Mean while, by this point, I am in tears from pain and can’t walk, sit, or stand.  I left after an L-spine x-ray was done, which showed nothing but stenosis, and was given a script, for Ultram and Valium (a pain killer and muscle relaxer, respectively).  I then spent the week in bed, literally.  I got somewhat better after a few days, as I could now walk without it hurting so badly and was moving at my less than normal speed.  I thought the worse was over and went about my business until the leg pain started, making it impossible for me to work.  After going through either intense back pain or leg pain for two months (the back pain I could control with ultram, but NO ONE knew what to do with the leg pain and I had no clue what was wrong with it), I got an MRI.  Because I am a hospital employee, I had access to my record.  I wish I didn’t.  The first MRI showed that I had herniations throughout my lumbar spine, the worse at L4-L5 and L5-S1.  That to me meant surgery if I continued to “complain” and I was not going to go through that.  I did physical therapy, but that made me hurt more, so I stopped.  I was in physical pain all the time now which made me depressed.  By October, my depression was so bad and I was doing stuff to harm myself, I got hospitalized.  The EMT that transported me to the hospital told me about chiropractors. I was extremely skeptical as they aren’t “real” doctors.  After about a month more of pain and my boss giving me hell for missing work and not being able to do my job (standing or sitting too long killed me. I could do one or the other for 4 hours before I was incapacitated.  Eight hours was too long for my back), I found a good chiropractor and starting the task of spinal manipulation.  It went well for about 6 months and I was finally pain free for a little while.  I should have stopped when the pain was gone but I wanted to stay pain free so I continued “treatment”.  By October of 2000, my leg pain returned and continued to get worse.  The back pain started again so I was back on the cycle of pain meds and rest and increased my sessions with the chiropractor so that I could be “better”.  By the end of January 2001, due to stress of work, the holidays, and not having a good therapist, I got hospitalized for depression, again.  My therapist that I was seeing in 1999 left in the summer of 2000 and I was without a “real” therapist, which contributed to the increased depression.  I had just started with my current therapist when it was too overwhelming for me to discuss my issues.  The best course of action was to get treatment via an inpatient stay.  Their beds suck and two days before I was too leave, my back was horrible and I couldn’t straighten out.  When I did, my back didn’t like it.  I was in really “bad” pain.  I begged the doc to let me out sooner (like now) and after some talking with my psychiatrist (I was also started with a new med), got discharged and then saw my chiropractor the next day (Friday, Feb 2, 2001).  The chiropractor did something that made me hurt like a son of a gun and did nothing to help my leg pain.  About twelve hours later, a friend of mine and I were at a bar waiting for her husband’s band to play when I collapsed in horrific pain.  My leg gave way and I couldn’t stand on it anymore.  My friend took me home and the next day, I stayed in bed, taking Valium, ultram, flexeril, thinking it was nothing and that I would be ok after a few days.  Yeah right, no such luck.  I got progressively worse.  On Monday, I went back to the chiropractor and she told me that I might need surgery and that if I wasn’t better the next day, go to the emergency room.  I couldn’t make it out of her office on my own and decided to go to the nearest ER that day.  It was the hospital that I was born in and thought it was a good hospital.  NOT.  The doctor there just saw me, gave me some pain shots (tramadol, I think), a script for Vicoprofen and I was on my way.   There were NO MRI or x-rays taken, no instructions to come back if symptoms got worse, nothing.  Mind you I couldn’t walk or feel my left leg like I could my right.  And my left foot was limp.  Oh well, I was fine and all I needed to do was “sleep it off anyway”.  Instead, I got worse. It had started to snow as I left the hospital, and I took a bad fall on my left side as I tried to get in my friend’s car.  Now I couldn’t even stand on my own and the pain worsened.  Two days later (day five of the disc fragment compressing my nerves), I decide to go to my work (the big hospital) and get checked.  I had called my psychiatrist as I had an appointment with her that day.  I told her what was wrong and she freaked out, saying that I should call an ambulance right now.  Up until that point, I just thought I needed physical therapy and good pain pills and I would be fine.  Hearing the stern command of calling an ambulance made me think this is more serious than I thought.  I spent several hours in the ER, and got an MRI at about one o’clock in the morning.   I knew I wasn’t going to be going home that night as by now, I couldn’t move my toes on either foot nor could I feel them.  The look on the radiology tech’s face was scary (she told me not to walk (ha like I could!) and I just shook my head like whatever lady).  This is about one a.m. when the moronic dumbasses (a.k.a. MD’s) tell me I have to have surgery. Until that time, I was goofing off with my co-workers, making the nurse’s life hell, and being a smartass with the residents to see what they really know.  Funny, but now they start freaking out as they have me transferred to a gurney (I was in a wheelchair to and from the MRI, and so that I can chat on the phone to whomever as I was bored as hell) and they put the bedrails up.  They won’t even risk me going to the toilet so I have to use a damn bedpan.  They tell me a disc fragment is pressing on my nerves (CES was NOT mentioned).  The neurosurgery resident tells me that I have to be catherized to check for urine retention.  I tell him nothing is wrong with my bladder, it’s my damn leg, stupid.  After they are huffing and puffing and I am refusing their demands, (they were “scared” to call their attending for a non-compliant patient), I tell them that I am NOT having surgery until after I sleep on it. (I had been up for about 24 hrs now, 14 of which have been in this stupid ER).  Nope, can’t do that. I have to decide right then and there and sign consents and off to the OR in a couple hours.  “NOPE, you are listening to me.” I said.  I said I need sleep and you are going to give it to me, I can’t make “rational” decisions on sleep deprivation like you.  Plus, no one on my “side” has said a word with me.  At four a.m., they paged my psychiatrist and I apologize for the call at this hour but these asses aren’t letting me have my way.  SHE tells me I have CES (Cauda Equina Syndrome) and I lost it as I knew I was “fucked” and may never walk again.  Ok, I will have the surgery but it better be with a board-certified surgeon or no deal.  This is what made all the residents get mad and scamper away.  I feel that residents just out of medical school should not perform operations as delicate as this, least of all on ME!  The board-certified surgeon comes in at 6:30 am looks at the MRI, exams me, then tells me 8:30 I am in the OR and leaves. He has a “great bedside manner”.  About seven a.m., I move up to the neuro floor and when I get there I make two phone calls, one to work saying I won’t be returning anytime soon; the second to my then best friend to thank her for her hospitality over the last few days. I then collapse to tears.  An RN, who is now one of my good friends, ask what is wrong and I tell her that I am having surgery and may never walk again.  I didn’t call my family as in my present condition would have freaked them out and scared the bejeezes out of them.  I begin the count down and my nurse notices I don’t have an IV (intravenous line).  She is angry with the ER and has to page the IV RN, stat.  I hear the page and cry harder, knowing she is coming for me.  Around 8:30, I am wheeled to the O.R., trying to get my tears in control.  It was about a half-hour later that I am put under and want to get the hell away before going through this ordeal (Course if I could run, I would have!!).

I wake up in the PACU (post-anesthesia care unit) and my left leg no longer feels like there is a tourniquet on it, but I now have compression boots to prevent any DVT’s (deep venous thrombosis, otherwise known as a bad blood clot).  I was completely out of it for a while and feel nausea from the anesthesia and vomit, which the surgeon decides to keep me on fluids for the next day or so.  When I am a bit clear headed, I realize I still cannot feel my feet or move my toes.  But I am thinking that it’s still early so maybe it will come back in a day or so.  The surgeon had said that it would be a couple days that I would return to normal.  When I was brought up from PACU, my family was there in my room.  I saw that my parents, who have not been in the same room together for about ten years, were there and I broke down some more.  It was difficult seeing them worrying about me.  The next morning the PT (physical therapist) came in and assessed how I was doing and tried to get me up and about.  That was a joke!  No sooner as my feet are swung out the side of the bed he notices my feet still drop.  He then confines me to bed until I get AFO’s (ankle-foot orthoses).  That was fun as now I can’t do anything but lie in bed.  I can’t even get up to use the bathroom.  That night, a nurse was on that I didn’t know and I had to use the bathroom.  The nurse’s aide came in and gave me a bedpan to use.  This was fine except for the damn compression boots.  I had an extremely full bladder and I now think that the morphine was causing me to retain my urine.  Anyway, here I am trying to go and every time I relax, the damn compression boots inflate/deflate disrupting my concentration!  I screamed at the nurse’s aide to remove them so I can urinate without it being a big deal, as I didn’t want the nurse to have to catherize me.  I finally go after she clears it with the nurse and void a hell of a lot of urine.

The hardest part of the whole ordeal during the time after surgery was realizing that I was no longer independent with my body functions.  Every time I had to use the toilet, I had to have two staff members with me.   One nurse held me up (strength in my legs were still weak) and the other nurse wiped me.  I was twenty-five years old and felt ashamed that I couldn’t do this on my own. It was terrible to feel like an infant in an adult’s body.

My psychiatrist visits me and I tell her that I still can’t feel my legs.  She knows the severity of my condition and I am still trying to cope with all of this.  I tell her the PT says I need to go into a rehab hospital, one that is right around the corner from the hospital.  Seeing that it’s Friday, I don’t think I will be leaving soon so it might be Monday that I am transferred.  Least that was what I thought.  Saturday, the PT comes in and fits me for the AFO’s.  I begin the arduous task of learning to walk again.  I am still in pain from the stitches and trying to get comfortable with the damn compression boots.  After my PT session, I collapse on the bed and cry.  It finally hits me that I am disabled and that I may never walk again.  All the dreams I had of playing my favorite sports (basketball and baseball) with my nephew are gone.  My co-workers come by and give me some stuff animals, which are great, as I love stuffed bears.  My good friend Ivan Hansen gave me a cute little stuffed beagle type dog that I fell in love with and my friends Betty and Dan gave me a HUGE teddy bear that I call Jonny (short for Jonathon, my favorite male name). I often held him during my bouts of crying depression, but he was often too big to stay on my bed (he’s about 3 ft tall!).  I got so overwhelmed at the prospect of not being able to return to work as my earned time and ESL (extended sick leave) were running low. Worries about finances and how to pay them soon left me in a suicidal depression.  My psychiatrist helped as much as she could and referred me to an inpatient psychiatrist that I could talk with daily.  I was now almost three weeks without formal therapy.  My therapist could not visit and there was no way for me to visit her.  Sometime during the week I called to give her an update and asked if we could have phone therapy.  To my amazement, she agreed.  She kept talking about the “trauma” my body was going through and I quickly thought that I did not want to talk about it so much.  (Course I talked about it for a year before I could go back to my regular issues that was the main reason why I was seeing her!)

So much for being able to walk a few days after surgery as it was almost a week before I could just wiggle my toes!  I got excited at the prospect of regaining my weaknesses in my legs.  It lifted my spirits somewhat but I was still depressed.  A few times I have to be watched by nursing staff because my moods were unpredictable.  I mostly wanted to jump out a window, but seeing the only thing I could do was crawl, it seemed unlikely.  I lost some weight because my appetite was decreased.  I was still waiting to get transferred to the rehab hospital.

It’s now Sunday, ten days post-op.  My nieces and nephew came to visit me and I am not feeling great today.  I go back on the bed where my niece accidentally kicks me in the back.  The stitches were removed that morning and my back was still sore.  I thought nothing of it and called the nurse for some pain meds.  Two days later, I am running a fever.  They rule out the usual, such as pneumonia and urine infection.  So far nothing indicates that there is a wound infection until the next day.  On Wednesday, February 21st of 2001, I notice a stain on my underpants that is on the elastic part of the waistband. I tell the nurse on duty and she calls in this nurse specialist (what an outpatient clinic would call a nurse practioner) and they page the attending doctor.  My surgeon and psychiatrist are on vacation that week.  The attending neuro-surgeon pushes some of the muscles in my back, which further breaks the pus pocket that has formed.  They tell me I need to have an MRI to determine how deep it is and I need to have surgery to drain and remove the infection.  I say I rather die than go through another endo-tracheal anesthesia.  The MRI shows that the infection is way down in the surgical bed and I thank god that I haven’t been transferred, as god knows what might have happened.  I finally consent after everyone talks me into another surgery as its urgently needed.  I am scared beyond belief.  Later that night, as I am wheeled again into the OR, I further panic as there is a fellow and an intern doing the anesthesia.  I don’t think I am going to wake up after this one, just sign my name and get control over the tears before I am placed under.  I come up from PACU and I am much more ill from the anesthesia the second time around than the first.  It takes me two days to recover from the anesthesia.  During this time, I am having trouble urinating on my own so the nursing staff has to catherized me least twice a day.  I am on good antibiotics so I don’t have to worry so much about a urinary-tract infection.  About this time, I find out that I am in acute renal failure from the antibiotics and one of them is extremely high so I have to be put on one of the less strong ones.  I now have to have a Foley catheter placed in my bladder as I am not urinating on my own.   A few days of this and my liver enzymes starts going up and I am placed on a stronger antibiotic with less liver damaging effects.  Because I was on an extremely high dose of neurontin, and my psychiatrist was away, it made me dopey and sleepy (course this time around, I was in a lot more pain and physically not up to par).  Once she came back, she quickly adjusted the dosage due to the renal insufficiency and I was less sleepy.  This second surgery kicked my butt as my stamina got down to nothing.  All it would take was a few steps before I was totally exhausted.  I also suffered from blood loss from the surgery that contributes to me feeling weak.  I have always been borderline anemic and this made me total anemic, almost to the point of having to receive a blood transfusion.  I remember during my in and out phase, that a co-worker came up to see me.  I thought he visited me three times.  I later learned that I passed out on him three times!  I spent about another week in the hospital.  I was seeing patients who just had a stroke and the like being transferred to the rehab hospital and I am just sitting there on my bed, watching the soaps or just trying to gather enough strength to make it to the lab (where I work) to check my email and say hi to my co-workers.  I am getting sick of being sick and want to go home.  I talk with my doctors about home care and they are willing to try it seeing that I can make do around with some support on the walker using the AFO’s.  The strength is back in my right leg and my left is getting a little stronger each day.

Luckily the second surgery didn’t make anything worse neurologically, even though I was in a lot more pain.  By the end of three weeks, I left the hospital.  I got home care so I could continue the IV antibiotics and have home physical therapy (PT). Least, I thought someone would come to my home and give me the antibiotics and instruct me in PT.  A nurse came to my house the day after I got discharged.  It took her a while to find my house as we had just got slammed with a snowstorm that morning and my streets weren’t exactly plowed as I live on a somewhat isolated area.  She got there and did her thing and informed me that she would set the IV up so that I can administer the vanco (vancomycin, the antibiotic used to treat my staph infection).  After a few days I mastered it and had the flow going good until one night I tripped over the tubing with the IV stand and the vanco gushed all into my living room rug.  I was cursing the home nurse for letting me do this on my own.

PT at home was a joke.  The therapist never stayed more than fifteen to twenty minutes (I timed it right with my soap operas and commercials).  She came like once a week, maybe twice if I was “available”, like I was not going to be home.  By this time, I was going downstairs to my room (I lived in the basement) and that was my physical therapy.  I found that going up and down the stairs helped tremendously with my balance and strengthened the weaknesses in my legs.  I slowly graduated to the cane after about two to three weeks.  I was moving slow, but with my left foot dropping, or rather slapping, it was the best I could do.

Three weeks into being home, I started to run fevers.  I was careful with the flushing of the IV and making sure the PICC line (a type of special IV placed in my arm) was covered so that I didn’t get an infection.  Plus with me being on a strong antibiotic, I didn’t think I could possibly get an infection.  I went to see my PCP and my white count is still slightly up and I still am in slight renal failure.  My doctor is pretty on the ball and was concerned.  I wait it out a couple days and then I am to call him if I still am having fevers.  I was and called him.   He tells me to go to the ER.  Great…I go and I am placed in the same damn bay I was the first time I was in the hospital.  I freak out and make everyone’s life hell.  The resident wants to do blood cultures and I tell him my doc did on Monday and they are negative.  The nurse comes in to start another IV and I tell her to screw.  The resident wants me to have another dose of vanco before I get discharged and I tell him my surgeon said I don’t need it so I am not going to.  I knew that if I did, I would have had to stay another damn hour in the bay and I didn’t want to.  I was already there for about eight hours.  The resident says he will remove the PICC line as they think it’s infected.  I say fine.  But they need to do blood work.  That’s when I tell them that only one person can do it and that is one of my co-workers who does phlebotomy.  He says no and then I tell him, tough luck then.  I am getting a kick out of having this much say over my care and telling them how I want to be treated.  My friend comes down and draws off the cultures and no sooner has she sent my blood off to the lab that the nurse comes in with my discharge papers.  Whoohoo, I can finally leave this place and never return again!  As I leave, one of the neuro-surgery residents comes chasing after me as my surgeon sent him.  He looks over the discharge papers and has me come back to the ER so he can do something.  Why, I am not sure.  He doesn’t exam me, probably gets the heads up from the nurse or the resident that I am a “non-compliant” patient and then lets me leave.

It’s now the middle of March 2001.  I am trying to get adjusted to the weakness in my legs and trying to feel normal.  I still have low stamina and it doesn’t take much for me to become easily fatigued.  Because of the winter and snow and ice, I can’t really walk outside.  I also would feel embarrassed as all my neighbors are older folks and here I am, younger than them by forty or more years, and have to walk with a cane or walker.  My balance is still off and my left foot “slaps” when I walk.

sick

Sick

Seems whatever has been going around in my family, I got. Been running fevers and feeling awful.

 

I haven’t been thinking much about what to write on my blog. Yesterday I went to the neuro-opt for my eyes. They couldn’t find anything wrong so chances are the reason for my blurriness is caused by migraine activity. I will need to get new glasses and then hopefully that will solve the problem.

Seems like my birthday has been cancelled. I am bummed out. With Everyone being sick it wouldn’t make sense. I’m not much for being in a party mood anyways.

 

I have been craving a meatball and black olive pizza. I might order it today but I doubt I can eat it as my throat is so sore. It’s rainy out so no chance of me going outside. I feel too crappy anyways. I just drank some chamomile tea. I hope it makes me feel better.  I have to take a shower sometime today as I have been sweating on and off and just feel miserable. I’m hoping a shower will help, least the steam can help my nose. My temperature is climbing back up.

 

I might type up some article I wrote later today. Depends on if I feel up to it or not. Article has to do with the stigma of suicide.

CBASP Cognitive Behavioral Analysis System of Psychotherapy

J. McCullough’s article in the Journal of Psychotherapy, “Treatment for Chronic Depression:  Cognitive Behavioral Analysis System of Psychotherapy”, (CBASP; McCullough, 2003) is divided into three sections.  The first section talks about the psychopathology of depression and breaks down how to define whether the patient has early-onset or late-onset depression.  The next part discusses the methodology of treating the patient with CBASP.  The third part details the summary of data used in the article.

McCullough uses Piaget’s pre-operational thinking to characterize the primary, structural, cognitive-emotional problems that he believes maintain chronic depression.  His belief is that chronically depressed adults somehow enter therapy thinking and emoting at the level of four to six-year-old pre-op children (p245).  He also states that chronically depressed patients are perceptually trapped in the present moment and are unable to step back and view social, interpersonal events as an objective observer.  Because of their inability to use formal, operational thoughts, the patients get caught in their own structural and intractable worldview (p245).  They are also powerless to understand the reasons why others react to them in negative ways.  Self-statements made by such patients can be summed up in the words of one who said, “The world is the way it is because I believe it.  I also believe that people will always hurt and reject me.”  Logical disagreement and reality-testing techniques are rarely successful.

McCullough states that there are many parallels between the chronic patient and the pre-op children (p.245).  He uses the examples of a child clinging to the idea that thunder is caused by a heavenly game of bowling despite the parent’s logical explanation of a sudden disturbance of air by an electrical discharge (p.246).  Therapists might challenge patients’ negative thinking by pointing out the positive things for him/her, but they still feel they are ultimately being rejected by accusing the therapist of having been “trained to be nice”, or that the therapist might like them now, but that is because they don’t know they well enough yet.  The patient does not think logically; therefore, logical challenge is not successful.

In order to begin successful treatment, psychotherapy begins with an adult child who must be assisted to mature development in the cognitive-emotive sphere.  Using Piaget’s theory of cognitive-affective development provides the etiological sources that define early-onset and late-onset types of depression: one source involves infants and children (early-onset) and the other involves adults (late-onset; p249).

The chronically depressed patient feels powerless to accomplish anything, lives in an environment that doesn’t influence what s/he does, generating empathy with others beyond his/her capacity, and that s/he has no existential future as it was in the past and the future is much of the same (p252-253).

CBASP is designed to address these problems by relying on predominant administration of negative reinforcement.  Therapists keep exposing patients to the consequences of their behavior at every turn.  The purpose of this is to change the patients’ behavior in a positive direction when their discomfort/distress is diminished.

The techniques of CBASP are Situational Analysis (SA), Interpersonal Discrimination Exercise (IDE) and Behavioral Skills Training and Rehearsal (BST/R).  Each session is broken down to 75% of the time (45 min) administering SA, 15% of the time conducting IDE (9 min), and 6 min spent in direct BST/R.

SA is a technique that is essentially a mismatching exercise.  By using a problematic interpersonal event and focusing on a piece of interpersonal time that has a beginning, middle, ending, and a personal interpretation of the story in between.         Instead of talking about their problems in a global manner, patients are now required to focus attention on a specific problem and are prohibited from talk about problems in general.  This enables a fertile generalization and transfer of learning potential –one SA exercise easily generalizes to numerous interpersonal events.

There are specific consequences of behavior in SA: an endpoint of the situation called an actual outcome, (AO) and the desired outcome for the same event.  After pinpointing what the AO of the interpersonal event was, they are asked to construct a DO of what they liked to have happened.  This usually demonstrates behavioral consequences and ends up causing distress.  As the discrepancy between AO and DO increase discomfort, the first phase of the SA exercise makes negative reinforcement possible.  The distress is often relieved during the end phase of SA when the situation is “fixed” and the patients learn what they must do to produce DO (p. 255).  By repeating the SA, the patient practices with formal operational thought by considering possibilities if they behaved differently.

There are two phases of SA: elicitation and remediation.  These phases are combined in a series of questions that the clinician asks the patient.  The questions pertain to describing the event in detail, thought/feelings about the incident, how the situation turned out, etc.    McCullough points out that these cognitive interpretations in CBASP serves as a descriptor of what is taking place in the situational event.   Thus, cognitive interpretations are never disengaged from the AO or the DO and are discussed independently.  He further states that this approach to cognitive pathology represents one difference between CBASP and Beckian Cognitive Therapy (p. 255-256).

IDE is based on the disciplined personal involvement of therapist with their client and is designed to correct the person’s misconceptions of the clinician.  This is done during session two, during which the clinician obtains the significant other history.  This is a list of persons who have had a determining and influential impact on the course of the patient’s life.  Each of these people is then described in terms of how he/she caused the individual to be the kind of person he/she is. The causal effect may be positive or negative.  Although patients do not think causally, the significant other history is the first time CBASP patients are required to think (in a mismatching way) in an “if this/then that” manner.  Some patients find it difficult to complete the exercise and thus fail to make the connection.  When the exercise is completed successfully, the therapist has an easier time generating causal theory conclusions about each significant other.  These conclusions are descriptive statements concerning how these people influenced the patient’s life (p. 257).  Once these conclusions are made, new interpersonal realities can develop.  This development can override the patients constant thought of always being hurt and rejected and strengthen the closeness of the therapeutic relationship.  This can then mitigate early damage that was inflicted on the patient by the significant other (p258).

In the BST/R, patients are motivated to modify their behavior when they are aware their behavior has consequences.  Once they realize that these consequences end their entrapment in there chronic depressive disorder, motivation to change is potentiated.  Through individually tailoring of the patient’s social skill training, rehearsal, and practice, chronically depressed patients exits the CBASP program to manage the situational challenge they encounter daily.

The study that was conducted to compare the efficacy of medication and CBASP was the largest study ever conducted in psychology and psychiatry.  Six-hundred-eighty-one chronically depressed patients were enrolled at 12 research sites throughout the United States.  They were randomly assigned 12 weeks of nefazodone (Serzone), CBASP, or a combination of both.  Patients were to have a score of 20 on the Hamilton Depression Scale for Depression (HDSD-24) to indicate depression.  Remission was defined as a score of 8 or lower at week 10 and 12.  All patients presented with a current episode of major depression that lasted on average of 7.8 yrs.  Those subjects diagnosed with antecedent dysthymia revealed an average history of dysthymia of 23 years.

The overall response rate was 48% for the monotherapy cells and 73% for combined therapy.  All subjects were included regardless if the acute phase was completed.  The results showed that combination therapy for chronic depression provides meaningful clinical advantage (p.260).  It also supports previous recommendations for using both psychotherapy and medication to treat chronically depressed patients.

Criticism:

            This article on a personal level was intensely difficult to get through.  I do not agree with most of what the author was saying about the pathology of depressed individuals and I certainly don’t agree that the depressed patient is responsible for their depression.  Once you get past his interpretation of the psychopathology, the methods of treatment were easier to digest and take in objectively.  I was disappointed that the study was so short in this article.  The description of CBASP took almost twenty pages, while the study was a half a page.  Overall, the article is promising in the treatment of chronic depression.  He also gives a very detailed account of how the session is timed, which leaves no room for talking about anything other than the situational event and provides greater attention to interpreting the precise event rather than the emotional one.

 

 

McCullough, J. (2003). Treatment for chronic depression: Cognitive behavioral analysis system of psychotherapy (cbasp). Journal of Psychotherapy Integration, 13(3/4), 241-263.

 

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