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.
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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