The ABCs of CBASP E-Book

Mark Berthold-Losleben

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2023

Beschreibung

Cognitive behavioral analysis system of psychotherapy (CBASP) is designed to help patients with chronic depression improve the negative social and personal impacts of this disorder. This volume, written by experienced practitioners of CBASP, creatively explores the principles and practice of CBASP in a new, unusual, and engaging fashion. Interspersed between theoretical chapters, you will find yourself in the therapy room with Maggie (the therapist) and Chris (the patient). Using authentic dialog, you will experience how the different stages of therapy unfold: How, from their first-person perspectives, Christopher and Maggie experience the application of the CBASP model, and how Helen (the supervisor) helps Maggie to understand difficult encounters in therapy. This book helps you prepare for your CBASP sessions by providing essential information and prompts in a clearly arranged manner, as well as exercises to verify your progress and learning goals. This creative and descriptive approach to understanding the hopes, fears, and concerns of patients and therapists engaged in a course of CBASP psychotherapy is essential reading for clinical psychologists, psychiatrists, other mental health professionals, as well as students wanting to know how to successfully apply CBASP.

Leseprobe

The ABCs of CBASP

A Guide to the Cognitive Behavioral Analysis System of Psychotherapy for Therapists and Clinical Supervisors

Mark Berthold-Losleben

Marianne Liebing-Wilson

John S. Swan

About the Authors

Mark Berthold-Losleben, PhD, MD, MA, is a consultant psychiatrist at St. Olavs University Hospital in Trondheim, Norway, and associate professor at the Department of Mental Health of the Norwegian University of Science and Technology (NTNU). He trained with Prof. James McCullough in 2016 in Amsterdam and was supervised by John S. Swan on his way to becoming a therapist, supervisor, and trainer in CBASP. Since 2018 he has been working closely with John S. Swan, Marianne Liebing-Wilson, and Bob MacVicar on making CBASP better known in Norway.

Marianne Liebing-Wilson, RMN, PG DIP CBT, was a senior adult psychotherapist with NHS Tayside and delivered the postgraduate CBT training program at the University of Dundee in Scotland together with John S. Swan. She trained with Prof. McCullough on several occasions on his visits to Scotland, and offered CBASP training to European colleagues with him in Amsterdam. She continues to offer training and supervision in CBASP in the UK and various European countries.

John S. Swan, MSc, BSc, RMN, RGN, PG DIP CBT, was a senior clinical lecturer and course director with the University of Dundee in Scotland. He trained with the originator of CBASP, Prof. James McCullough, in 2006 and was fortunate enough to be supervised by Prof. McCullough for three years after his training. John S. Swan is now retired but continues to offer training and supervision in CBASP upon request.

Library of Congress of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2022952111

Library and Archives Canada Cataloguing in Publication

Title: The ABCs of CBASP : a guide to the cognitive behavioral analysis system of psychotherapy for

therapists and clinical supervisors / Mark Berthold-Losleben, Marianne Liebing-Wilson, John S.

Swan.

Names: Berthold-Losleben, Mark, author. | Liebing-Wilson, Marianne, author. | Swan, John S., author.

Description: Includes bibliographical references and index.

Identifiers: Canadiana (print) 20230132537 | Canadiana (ebook) 2023013257X | ISBN 9780889375840

(softcover) | ISBN 9781616765842 (PDF) | ISBN 9781613345849 (EPUB)

Subjects: LCSH: Depression, Mental—Treatment—Handbooks, manuals, etc. | LCSH: Cognitive therapy—

Handbooks, manuals, etc. | LCSH: Psychotherapy—Handbooks, manuals, etc. | LCGFT: Handbooks and

manuals.

Classification: LCC RC537 .B475 2023 | DDC 616.85/270651—dc23

© 2023 by Hogrefe Publishing

www.hogrefe.com

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

Registered trademarks are not noted specifically as such in this publication. The use of descriptive names, registered names, and trademarks does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

The cover image is an agency photo depicting models. Use of the photo on this publication does not imply any connection between the content of this publication and any person depicted in the cover image.

© ljubaphoto – iStock.com

PUBLISHING OFFICES

USA:

Hogrefe Publishing Corporation, 44 Merrimac Street, Suite 207, Newburyport, MA 01950

Phone [phone]; E-mail [email protected]

EUROPE:

Hogrefe Publishing GmbH, Merkelstr. 3, 37085 Göttingen, Germany

Phone [phone], Fax [phone]; E-mail [email protected]

SALES & DISTRIBUTION

USA:

Hogrefe Publishing, Customer Services Department, 30 Amberwood Parkway, Ashland, OH 44805

Phone [phone], Fax [phone]; E-mail [email protected]

UK:

Hogrefe Publishing, c/o Marston Book Services Ltd., 160 Eastern Ave., Milton Park, Abingdon, OX14 4SB

Phone [phone], Fax [phone]; E-mail [email protected]

EUROPE:

Hogrefe Publishing, Merkelstr. 3, 37085 Göttingen, Germany

Phone [phone], Fax [phone]; E-mail [email protected]

OTHER OFFICES

CANADA:

Hogrefe Publishing Corporation, 82 Laird Drive, East York, Ontario M4G 3V1

SWITZERLAND:

Hogrefe Publishing, Länggass-Strasse 76, 3012 Bern

Copyright Information

The eBook, including all its individual chapters, is protected under international copyright law. The unauthorized use or distribution of copyrighted or proprietary content is illegal and could subject the purchaser to substantial damages. The user agrees to recognize and uphold the copyright.

License Agreement

The purchaser is granted a single, nontransferable license for the personal use of the eBook and all related files.

Making copies or printouts and storing a backup copy of the eBook on another device is permitted for private, personal use only. This does not apply to any materials explicitly designated as copyable material (e.g., questionnaires and worksheets for use in practice).

Other than as stated in this License Agreement, you may not copy, print, modify, remove, delete, augment, add to, publish, transmit, sell, resell, create derivative works from, or in any way exploit any of the eBook’s content, in whole or in part, and you may not aid or permit others to do so. You shall not: (1) rent, assign, timeshare, distribute, or transfer all or part of the eBook or any rights granted by this License Agreement to any other person; (2) duplicate the eBook, except for reasonable backup copies; (3) remove any proprietary or copyright notices, digital watermarks, labels, or other marks from the eBook or its contents; (4) transfer or sublicense title to the eBook to any other party.

These conditions are also applicable to any files accompanying the eBook that are made available for download. Should the print edition of this book include electronic supplementary material then all this material (e.g., audio, video, pdf files) is also available with the eBook edition.

Format: EPUB

ISBN 978-0-88937-584-0 (print) • ISBN 978-1-61676-584-2 (PDF) • ISBN 978-1-61334-584-9 (EPUB)

https://doi.org/10.1027/00584-000

Citability: This EPUB includes page numbering between two vertical lines (Example: |1|) that corresponds to the page numbering of the print and PDF ebook versions of the title.

Dedication

To my beloved and most significant others in order of their appearance: Katrin, Anouk, Lucia, and Carla.

Mark

To my family who have supported and believed in me, even when I doubted myself.

Marianne

To Dr. Rob Durham, now sadly deceased. A finer friend, colleague, and mentor there never was.

John

|vi|Acknowledgments

Marianne and John, it has been a real pleasure to work with you. I thank you for this amazing journey and hope this wasn’t our last project. To be continued.

I also thank my wife Katrin for her very honest and most valuable feedback, my parents for their support, and my children for how wonderful they are.

Thanks to my former head of department, Anne-Cathrine Svenning, who helped create the environment to start with CBASP in Norway.

Finally, I want to thank James McCullough who dedicated his life to develop this exciting and important psychotherapy and had a great impact on me and my view of the chronically depressed patient. Thank you, Big Jim, for writing these kind words in your foreword.

Mark Berthold-Losleben

I’d like to thank the late Rob Durham, my mentor and friend who introduced me to CBT. John Swan and Bob (the Bobster) MacVicar who taught me how to teach and who have travelled far and wide with me to spread the word about CBASP.

Thanks go to Mark for being bored during the pandemic and coming up with the idea to write a book – what a blast we had!

And last but not least, Big Jim (McCullough) – thank you for being such a force of nature and a tremendous psychotherapist!

Marianne Liebing-Wilson

Marianne and Mark, we figured out a useful way to spend the pandemic by working on this text. You both made completing the book such a straightforward pleasure.

I offer up a big thank you to my wife Sybille for being so supportive.

Finally, gratitude to Professor James McCullough whose friendship and mentorship made the last 16 years of my career even more enjoyable than it was the 30 plus years before CBASP.

John S. Swan

Contents

Acknowledgments

Foreword

Preface

1  Introduction

2  Christopher

3  Maggie

4  Timeline

5  Significant Other History

6  Transference Hypothesis and Interpersonal Domains

7  Kiesler’s Theory of Interpersonal Styles

8  Groundhog Day

9  Case Formulation in CBASP

10  Introduction to Situational Analysis

11  The First Situational Analysis

12  Spotting a Hotspot

13  Another Situational Analysis

14  Interpersonal Discrimination Exercise

15  Disciplined Personal Involvement

16  When You Get What You Want and Future Situational Analysis

17  Ending Therapy

18  The Good CBASP Therapist

Glossary and Abbreviations

Appendix

Peer Commentaries

|1|Foreword

My relationship with the CBASP Scottish Connection began in 2006. Four Scottish lads came to Richmond, VA, to spend a week with me to talk about CBASP. We spent a delightful 6 days together studying, role-playing therapists and patients in situational scenarios, discussing chronic depression, laughing, and boisterously hurling jokes at one another – then, of course, eating and drinking. My workshops have always been held in a wonderful church setting, and thank goodness our location was in the farthest wing of the educational building on the second floor with the door tightly closed – out of sight and sound. They had “done it right” from the beginning by taking my first book from 2000 and discussing it together regularly over an extended time while seeing patients in Dundee, Scotland. The quartet became highly familiar and conversant with CBASP methodology, and by the time they traveled to Richmond, the group was ready to move into an advanced training mode – and that we did! Over the years, I have urged their model of preparation before CBASP workshop participation to hundreds of professionals who have attended my training sessions: Prepare before you come to enhance your learning experience!

Some 10 years later, Mark, who lives and practices CBASP in Norway, joined a 5-day workshop with me and the Scottish group in Amsterdam, which included Marianne (originally from Germany, but now an honorary Scot), and was quickly adopted by them into their circle.

Now, 5 years later, comes their gracious invitation to write a foreword for their new text, The ABCs of CBASP: A Guide to the Cognitive Behavioral Analysis System of Psychotherapy for Therapists and Supervisors, which I happily consented to do.

Their presentation of CBASP is the most creative and descriptive approach I have ever read. To use a phrase employed in some popular literature reviews, this text is a page-turner. It is engaging and highly informative. Their book begins as it should with a definition of chronic depression or persistent depressive disorder (PDD) and the caveat on the part of the authors that PDD will be referred to herein as chronic depression. Chapter 1 describes the nature of the chronic patient and how CBASP diagnoses the individual. The reader is immediately impressed with how difficult it is to treat the patient with the several interpersonal obstacles one frequently encounters during the treatment process. Not only do patients bring a destructive lifestyle to therapy, they also function on a primitive maturational level that requires psychotherapists to relate to someone unable to utilize formal operational language in the interpersonal sphere. Most chronic patients are interpersonally avoidant and frightened of interpersonal encounters; they are also perceptually disengaged, in an essential way, from recognizing their connection to their social environment. This latter deficit makes environmental feedback noninformative and maintains the state of |2|chronicity. Put differently, patients often report that “Today is like yesterday with tomorrow boding only more of the same” – they are persons caught in time and without a future.

Following a sketch of the patient, the authors describe the various CBASP techniques in Chapter 1. They paint a deft picture of how and why CBASP approaches the chronic patient as it does. In Chapter 2, the format of the text radically changes. Most of the remainder of the book creatively presents verbatim interactions of a patient (Christopher) and his therapist (Maggie) to describe the unfolding process of CBASP therapy. Woven into this verbatim fabric are the internal dialogues of Maggie’s self-doubt as she continuously worries that she is moving too rapidly for Chris. In the initial sessions, Maggie frequently asks herself whether she is coming on too strong and running the risk of Chris terminating treatment. Presenting CBASP from a verbatim dialogue perspective is nothing short of engaging and informative. The style of the book is so highly realistic that the reader is thoroughly caught up in the process of the dynamic interactions from a moment-to-moment basis. I’ve never seen any therapy model presented and described to the reader using such verbatim interactions in this manner.

In Session 1, Maggie and Christopher move through the diagnostic task of delineating the course of Christopher’s early-onset depression since childhood. Next, we read about the administration of the Significant Other History (SOH) leading to a formulation of Maggie’s transference hypothesis, all in verbatim style. In Chapter 7 we get an intimate look at how Maggie introduces Christopher to D. J. Kiesler’s Interpersonal Impact Message Inventory (IMI) and how she then, leaving the verbatim mode briefly, comes to a delineation by the authors of the CBASP procedures utilized to formulate the case (Chapter 9).

What is so intriguing about this book is that all the verbatim dialogues interspersed between brief and periodic descriptions of CBASP methodology have a stop-and-start quality that mimics the reality of the unfolding process of actual clinical cases. The effect is to keep pulling the reader from an observer perspective into a participant mode as the verbatim exchanges continue.

The verbatim interactions resume as Christopher is introduced to situational analysis (SA), the major change strategy of the model; subsequently, we travel through Christopher’s first experience with SA. Next, we see the administration of the interpersonal discrimination exercise (IDE) and view how the transference hypothesis is employed when a hotspot is exposed within a dyadic interaction. Readers find themselves in the therapy room with Maggie and Chris as she uses the IDE to differentiate herself from malevolent Significant Others (SO) who have previously hurt him.

The verbatims throughout this book highlight the uniqueness of the clinical role of a CBASP therapist: Disciplined personal involvement (DPI). This role becomes obvious through Maggie’s verbatim interactions with Christopher. Chapter 15, again leaving the verbatim mode, presents a brilliant description of the DPI role. I’ve never read a more compelling justification for the utilization of DPI in CBASP’s treatment of the chronic patient than found in this chapter. The authors sensitively describe the actualization of the “comrade role” to an individual who likely has never experienced one, justifying it unequivocally. Verbatim dialogue characterizes the following Chapters 16 and 17 as we participate with Maggie to bring the case to a close when Christopher meets the criteria for CBASP treatment termination.

|3|In the final Chapter 18, we find Maggie self-reflecting about her role in the therapy with Chris and the skills required to become a good CBASP therapist.

If you have been looking for a text that describes the CBASP in an exciting fashion, this text is it! As noted above, the reader will likely experience this book primarily as a participant and in the process of full participation also obtains an excellent and informed description of what the CBASP model is all about. Bravo to the authors for this unique text!

James P. McCullough, Jr., PhD

Emeritus Professor of Psychology

Virginia Commonwealth University

Richmond, VA

|5|Preface

Many well-documented difficulties occur in the psychological treatment of chronically depressed people. Most patients suffering from chronic depression are not easy to treat and often not easy to even have around. The effects of chronic depression on patients can leave the impression of their being socially incompetent, ill-prepared for therapy, the only one in the room, invisible, untreatable, and not worth the trouble. The list could be longer. Even experienced therapists sometimes enter sessions with a lump in the throat, a feeling of discomfort, and the reflexive wish to hand the patient off to a colleague. However, we are convinced there is a better alternative. Anyone who wants to help patients to manage their chronic depression should take a closer look at the cognitive behavioral analysis system of psychotherapy (CBASP).

Developing expertise in any psychological therapy is a challenging process. During the application in the clinical setting, no experienced teacher or accredited therapist has the beginner’s back or can guide them live through the sessions or show them how specific interventions are properly done. Even though it is possible to reflect on video or audio recordings afterward, it is still difficult to prepare for early or initial cases. The transition from theory to clinical application is often tricky and may represent an off-putting threshold. This is certainly the case when it comes to moving into the clinical application of CBASP. Indeed, one could argue that the challenge of moving from novice to expert with this system is more taxing given the particular skills needed to become a good CBASP therapist. Disciplined personal involvement (DPI), contingent personal responsivity (CPR), and interpersonal discrimination exercises (IDE) are virgin soil to most psychotherapists. Especially for those who have learned other forms of psychological treatments, these CBASP procedures are generally uncommon and can be uncomfortable. Trainees undertaking CBASP and attendees at CBASP workshops often express concern about being open, honest, and direct about their experience of finding the impact of chronically depressed individuals’ behavior on them as being anxiety-provoking.

We, the three authors, were all trained cognitive-behavioral therapists before we first came upon CBASP. From the very beginning, we liked and realized how meaningful this approach could be to us and how much more it had to offer for the chronically depressed patient. We never considered it to be a replacement but rather a supplement to our repertoire. After having become trainers, in recent years we have been busy introducing CBASP to a growing community of interested therapists, most of whom now use it as their therapy of choice when helping people who suffer from chronic depression. The experiences that the attendees of our courses have shared with us often reminded us of the experiences we had ourselves when attending the courses of James McCullough and observed the |6|roleplays demonstrating the administration of the various CBASP techniques. We thought: “That’s not too hard. Look, how easily he does that. We can do that, too.” But that is not what we felt upon actually trying to apply CBASP to patients. What seemed to be natural for Professor McCullough in his training courses proved to be difficult to apply in real life. The problem was not understanding the logic behind the principles and procedures of CBASP, the problem was how to do it. “What do I say? When do I say it? How can I be involved in a disciplined manner? How am I supposed to tell the patient what they make me feel like?” To a certain extent, one can rehearse a session in advance, but during the session, you are more or less on your own.

Therefore, we chose to conceptualize this book as a new approach to help those interested to gain insight into and possible expertise in this exciting new therapy. This is not the usual textbook about psychotherapy in general or CBASP in particular. Indeed, you might want to read at least one additional text about CBASP. Rather, we guide the reader through a whole course of therapy with our characters Christopher, who is chronically depressed, Maggie, who is an experienced CBASP therapist, and Helen, her even more experienced CBASP supervisor.

After providing a short introduction to the therapeutic techniques of CBASP and the psychopathology of chronically depressed patients, we allow our main characters to share with the reader insights into their part in the narrative of therapy from a first-person perspective. Most of the chapters are in dialogue form with a focus on the therapeutic relationship. These are then followed, respectively, by a third-person supervisee perspective with a consciously more textbook style approach to analyze what was happening in the room between the patient and the therapist. Maggie’s conversations with her supervisor, Helen, serve to illustrate how Maggie reflects on the nature of the patient, the work in progress, the mistakes made, and the skills needed to apply a course of CBASP.

Whenever appropriate, we close the narrative-based chapters with boxes providing important information that highlights key points and learning goals as well as suggests homework and recaps what has been learned. Sometimes chapters also provide information about preparations that need to be done by the therapist for the next session. Blank versions of the worksheets used in CBASP can be found in the Appendix. Christopher and Maggie thus illustrate how a course of CBASP therapy can unfold and what problems might arise or what therapeutic disconnects (arising and felt in moments when the atmosphere in the room during the session shifts from one of cooperating in harmony to one of the sensation of therapeutic disruption and discomfort for both parties) therapists offering therapy might unwittingly step into. We recommend reading the book completely before using the glossary at the end to navigate more specifically to topics of personal interest.

In medicine there is a common phrase: See one, do one, teach one. This book is meant to help with the seeing. We hope it will empower our readers to be less scared about the doing.

Mark Berthold-Losleben

Marianne Liebing-Wilson

John S. Swan

|7|1  Introduction

Offering therapy to anyone in distress presents the therapist with numerous challenges and associated tasks. The three core tasks throughout therapy are:

To establish, foster, and maintain a working alliance that is collaborative and encourages the person seeking help to move toward taking on a participant role in behavioral and emotional change.

To construct an accurate case formulation of the patient’s problems which establishes and clarifies how both current and historical circumstances have influenced the problems in living the patient is experiencing in the here and now.

To offer an effective treatment strategy specifically targeted to ameliorate those problems in living.

Significant challenges face both the person seeking help and the therapist in meeting these three core tasks. These challenges can be distilled into three core factors:

The breadth and complexity of the characteristics of the person seeking help.

The nature and complexity of the diagnosed disorder and concomitant problems in living experienced by that person.

The fact that most therapists work in situations of significant clinical pressures where there are often limited resources and support (Durham et al., 2000).

The cognitive behavioral analysis system of psychotherapy (CBASP) is a psychological therapy specifically designed to enable therapists to help individuals who experience chronic depression (CD). Please note that we do not make a clear distinction between the terms chronic depression and persistent depressive disorder. In this book, we prefer the use of chronic depression, as we think it is a more common and probably a better understandable expression also for people not working in healthcare. However, therapy-resistant depression, often used to refer to chronic depression, is – as far as we are concerned – a less diagnostic and more clinical and to date unstandardized term, which we avoid using due to the lack of a broader consensus (see also McIntyre et al., 2014). The CBASP model is predicated on directly addressing the tasks and challenges outlined above (McCullough, 2000, 2001, 2002, 2006; Swan & Hull, 2007). Our clinical experience over many years of attempting to help those with chronic depression led to the realization that the treatment of this disorder calls for a different approach, which is reflected in the literature calling for specific models for treating chronic depression both psychotherapeutically and pharmacologically (de Maat et al., 2007; Fournier et al., 2009; Keller et al., 2000; Keller, 2001; Schramm, Hautzinger et al., 2011; Schramm, Zobel et al., 2011; Swan et al., 2014; Thase et al., 2001). Later in this |8|chapter, we unpack the principles and procedures within the CBASP to provide a preparatory insight into what follows in subsequent chapters. For now, we want to map out the particular signs, symptoms, and characteristics of chronic depression.

The Nature of Chronic Depression

Chronic depression in DSM-5 is exclusively referred to as persistent depressive disorder (PDD) and is defined as experiencing a depressed mood for most of the day on more days than not for 2 years or longer; the person is never without symptoms for longer than 2 months.

DSM-5 provides a symptom checklist algorithm that includes specifiers such as persistent major depressive (MD) episode, PDD with intermittent MD episode with and without a current episode, and pure dysthymic disorder (APA, 2013). Although DSM-5 may not live up to all of the multifarious distinctions McCoullough presents in his research and various other books about chronic depression, the inclusion of such specifications at all can be attributed to his efforts.

ICD-10 of the The World Health Organisation (WHO) seems to be less sophisticated when it comes to defining chronic depression, and indeed ICD-11 fails to add to ICD 10 in any substantial way. Dysthymic disorder or chronic depressive personality disorder or dysthymia as approximate synonyms are coded under F34 persistent mood [affective] disorders in the ICD-10; different subtypes are not explicitly included. The disorder is considered to be rather mild and does not take into account the severity of the symptoms and different courses of disease we encounter in everyday clinical practice.

Complexity and Characteristics of Chronic Depression

Prevalence and Persistence

Chronic depression is a disorder that develops over years, rarely remits spontaneously, and can last for decades (Al-Harbi, 2012; Klein, 2010). One in five adults with a major depressive disorder goes on to develop a chronic course (Arnow & Constantino, 2003; Kessler et al., 1994; Spijker, 2002; Torpey, 2008), with the lifetime prevalence of chronic depression estimated at 3% to 6% in community and primary-care samples (Murphy & Byrne, 2012; Satyanarayana, 2009; Young et al., 2008). The mean duration of chronic depression episodes ranges from 17 to 30 years. In contrast, nonchronic presentations have a mean duration of 20 weeks (Gilmer et al., 2005; Kocsis et al., 2008). Klein and colleagues (2006) found that individuals with a chronic illness were 14 times more likely to have a chronic presentation 10 years later. In addition to long periods of illness, once affected, people who develop persistent depression tend to have an earlier onset of their mood disorder than |9|those with acute depression with fewer lifetime episodes and longer episode duration (Angst et al., 2009; Klein et al., 2004; Mondimore et al., 2006).

Response Rates and Influences

Chronic depression is associated with slower rates of improvement over time and with poorer response rates to psychological and pharmacological treatments (Cuijpers et al., 2010; Cuijpers et al., 2013; Klein et al., 2006). Factors associated with poorer outcomes are related to the tendency for chronically depressed persons to have higher rates of comorbidity on Axis I (anxiety disorders) and Axis II (personality disorders) conditions (Gilmer et al., 2005; Klein et al., 2006). Anxiety disorders are frequently comorbid in individuals with chronic depression, and these disorders share a wide range of symptoms. Simple phobias, social phobia, general anxiety disorder (GAD), and panic disorder are typically found when assessing chronically sad individuals. The presence of a comorbid anxiety disorder appears to deepen clinical sadness and the risk for suicide is increased. General functioning is adversely affected too (Kornstein, 2001; Thase et al., 2001). In addition to these extra burdens, chronic depression with early-onset is strongly correlated with the presence of personality disorders, with prevalence figures ranging from 14% to 85% with the mean at 50%. The characteristics and symptomatology of chronic depression and personality disorders, particularly in Clusters B and C, share core features such as sadness, poor social functioning, early developmental trauma, and hopelessness.

Childhood trauma or early adversity plays a significant role in the development and course of all the depressive disorders (Alloy et al., 2006; Heider et al., 2006; Hill, 2003) and is one of the strongest predictors of chronicity (Brown et al., 2008). Early adversity is also associated with the duration of episode or persistence, with this finding being more significant in samples of chronic depression (Klein et al., 2009). Early adverse life events have also been found to be correlated with earlier onset of mood disorder and a greater number of episodes across the lifespan taking on a more chronic course (Angst et al., 2011; Bernet & Stein, 1999; Brown & Moran, 1994; Moskvina et al., 2007). Childhood maltreatment/early adversity appears to influence treatment response in those with persistent depression as well. Individuals who reported early adversity benefited more significantly from CBASP than from pharmacotherapy or therapies not specifically designed for persistent depression (Klein et al., 2018; Nemeroff et al., 2003).

As Schramm and colleagues (2020) highlight, chronic and nonchronic depression are related but different. The differences are compiled in items 1 and 2, in the challenges section at the beginning of this chapter, namely: the breadth and complexity of the characteristics of the person seeking help and the nature and complexity of the diagnosed disorder and concomitant problems in living experienced by those affected by chronic depression.

In summary, the complexities that represent the challenges to therapists when treating those with chronic depression are as follows:

Greater comorbidity with anxiety and personality disorders;

Increased likelihood of early adverse life events and mistreatment with associated problems with authentic empathy and trust in relationships;

Interpersonal fear and sensitivity;

|10|Earlier onset of depressive symptoms;

Periods of more frequent and longer-lasting illness and more prone to recurrent episodes;

Increased interpersonal functional impairment;

More severe levels of depressive symptoms with an associated increase in suicidal/self-harm behavior;

Avoidant, submissive, and hostile interpersonal behavioral repertoires;

Increased preoccupation with hopelessness, helplessness, and therapeutic nihilism.

Today, it is clear that the tenacious nature of this disorder indicates the necessity of longer courses of treatment, both psychotherapeutically and pharmacologically. At the same time, it makes sense to have treatment plans that target the core disturbed mechanisms that give rise to the problems in living experienced by the individual. Familiar and well-established psychotherapy models employed to treat acute depressive disorder have been shown to have poorer outcomes when applied to chronic depression. The use of psychological therapy with an interpersonal focus, specifically CBASP, was recently recommended (Jobst et al., 2016). Schramm and colleagues (2020) call for treatment strategies for chronic depression that address and target:

Supporting the patient’s mentalizing capabilities;

Recognizing the consequences of one’s own behavior;

Developing authentic empathy;

Increasing motivation and overcoming avoidance;

Improving active social problem-solving, including social skills;

Healing interpersonal trauma (including being able to connect with and trust other people);

Improving depressive symptoms, such as hopelessness and helplessness;

Improving the quality of life and reducing other comorbidities.

Although CBASP has the potential to increase the quality of life for a significant number of chronically depressed patients, it appears best to orient patients toward expecting a lifelong disorder they must learn to manage (McCullough Jr. et al., 2015). Schramm and colleagues (2020) reveal that, compared to a placebo-like approach, the benefit of CBASP subsided after a 2-year follow-up (Schramm et al., 2020), which supports McCullough’s assumption that patients need to apply the strategies learned in a course of CBASP continuously to maintain the effect.

The Cognitive Behavioral Analysis System of Psychotherapy

The Oxford English Dictionary defines a system as “a set of things working together as parts of a mechanism or an interconnecting network; a complex whole” or “a set of principles and procedures according to which something is done; an organized scheme or method.” The unique structure of CBASP forms a system within which the principles and procedures |11|are operationalized (see Figure 1). The system carefully provides everything we need to know and do. It has clear guidelines on how to proceed in every phase and step across the procedures. Both novice and experienced CBASP therapists would do best to learn and adhere to the guidelines/protocols. Some may find the thought of observing a system and adhering to protocols an anathema, worrying that it might stifle their creativity and lead to mechanistic or depersonalized therapy. Our thoughts and experiences while becoming accredited CBASP practitioners, training others, and supervising new CBASP therapists are clear: If you learn and follow the guidelines/protocols in initial learning cases, then it becomes increasingly possible to exert a flexible and informed response. Further practice and familiarity with the principles and procedures provide guidance when one becomes lost and uncertain. It also becomes possible to tailor therapeutic responses in sessions/cases that have become challenging and problematic while maintaining fidelity to the model. Therapist drift because of fidelity to the model is more likely when therapists are anxious and uncertain about how to proceed. With difficult patients or in unusual situations that promote anxiety, concern, hostility, or uncertainty/passivity in both parties, therapists and patients alike revert to fixed ways of thinking and operating, usually falling back on what they know best – for therapists the psychological therapy most practiced and familiar to them. The result is confused therapists with confused patients who experience poorer therapeutic outcomes (Waller, 2009; Waller & Turner, 2016).

An Overview of CBASP Principles and Procedures

Principles

CBASP principles conceptualize chronic depression as the dysregulation of mood generally stemming from a history of early adverse life events or maltreatment as variants of neglect and abuse experienced by children and young adults.

CBASP does not rely on Beckian assumptions of an inside–out path to understanding the psychopathology or treatment of depressive disorders. Rather, CBASP principles conceptualize problems in living as an outside–in process.

We all live in environments (the outside) that, no matter how we may try to limit contact with others, result in a rich social environment. We must interact with others for all we need in terms of physical, spiritual, and social/intrapersonal health. We influence our environment and our environment influences us. This reciprocity gives rise to both proximal and distal consequences. We inevitably read or interpret the actions and intentions of others in these social encounters (the inside). Additionally, learned expectancies, with their roots and origins in previous experience, influence how we read others. If you are lucky enough to feel physically and psychologically well and have had a preponderance of love and good regard from Significant Others (SOs) in your early years, you tend to interpret the actions of others positively. You may be reasonably accurate and in tune in such interactions. This experience of nurturing relationships with SOs instills in you the optimal outcome of functional interpersonal abilities. Those of us fortunate to have had such histories with SOs have developed the gift of being able to generate empathic and compassionate |12|responses toward others, enabling us to connect with, understand, and make ourselves understood to other people. We possess the capacity to adapt our interpersonal behavior in connection with changing interpersonal demands across social situations and to take account of the varying behaviors, needs, and intentions of other people. This interpersonal flexibility – the ability to adapt interpersonal behavior in reaction to the challenges of different interpersonal demands – is a characteristic of mature psychosocial functioning (McCullough Jr. et al., 2015).

However, persons with chronic depression are unlikely to feel well physically or psychologically upon encountering people who say they want to help or seem interested in them. Individuals with chronic depression are more likely to have had histories of adverse events, where love, positive regard, and acceptance were in short supply. They may even have histories in which benign disinterest/neglect or even open physical and psychological abuse were the norm, with negative and punishing consequences presented in their interactions with family, friends, or those in some authority over them.

The chronically depressed individual is more likely to have the learned expectancy that allowing another person to get to know them, becoming close in terms of knowing who they are, and trusting them will lead to unpleasant consequences. And yet this is what therapists are required to do: Therapists purposefully try to get to know the person in front of them. Therapists and patients need to move toward trust, closeness, and a clarity of what is wrong and what might be done about the patient’s problems in living. All the therapists we have met simply want to help. They work hard to foster trust and establish a good working alliance; they endeavor to project a clear picture of warmth, positive regard, and be someone the patient learns to trust.

The challenge for those of us who want to help the chronically depressed is this: The depressed person most likely does not experience the encounter(s) that way. Their learned expectancy leads them to read the situation in habitual and reflexive ways, namely, expect the worst, expect criticism, expect rejection, expect disapproval, expect ulterior motives, expect harm, expect friendliness to turn into hostility: Don’t trust this person and don’t trust their friendliness. Those are the reads, the meanings or situational interpretations that guide the depressed person’s behavior. Therefore, in CBASP thoughts are important, but these situation-specific thoughts are viewed as habitual responses or reads acting as a set of self-instructions giving rise to behavior in interpersonal encounters. Seeking safety from demeaning psychological insults – or worse, from frank psychological-emotional abuse both purposeful and accidental (e.g., parental death/separation) at the hands of SOs – leads to interpersonal retreat resulting in life-long emotional dysregulation and negative views of the self concerning others (McCullough, 2000, 2006; McCullough Jr. et al., 2015; Uher, 2011). Furthermore, chronically depressed patients are constrained by their interpersonal rigidity and are unable to shape their interpersonal responses to meet the changing demands of varying interpersonal situations. Depressed people can be said to be “stuck in a rut,” unable to regulate/modify emotional, behavioral, and cognitive styles (Holtzheimer, 2011).

James McCullough, the originator of CBASP, invites us to consider that adults with chronic depression suffer from an arrested maturational development that mimics or approximates the Piagetian preoperational stage. Arrested maturational development is thought to originate in the early experience of maltreatment. A significant proportion of those with early-onset chronic depression reports early adverse life events. The maltreated individual retreats into themselves with a focus on staying safe with an |13|accompanying state of elevated anxiety/fear throughout childhood and early teenage years. This heightened state of fear results in an arrest of the normal cognitive-emotional maturational process. The child/young adult becomes trapped in the preoperational stage (Piaget, 1926/1923). For those who report late-onset depression (21 years or over), chronic depression in later life is more often associated with a specific stressful life event that triggers the index episode of depression (McCullough, 2000). Either the index episode persists, or the person goes on to develop increasingly more frequent episodes of depression that slowly merge into persistent dysphoria. Insidiously, the world appears unworkable (producing hopelessness) and problems in living appear irresolvable (producing helplessness). Over time, this frame of mind becomes all-consuming, leading to preoperational thinking with the inevitable conclusion that “Life will always be this way.” Thus, the late-onset sufferer experiences a general functional regression to the Piagetian preoperational stage.

A particularly influential aspect of the preoperational relationship with the social world is the tendency of persistently depressed individuals to be perceptually disconnected from the relationship between their behavior and the emotional and interpersonal consequences for their lives. Bad things just seem to happen. People just seem to lose interest in them. Friends and family appear to be angry/hurt or become distant for no obvious reason. The disconnected person concludes: “This is just the way things are. Nothing I do makes any difference, and there is no point in trying as there is no chance of betterment.”

Piaget believed that cognitive development occurs in four stages, characterized by qualitative changes in the nature of thinking:

Sensorimotor stage (0–2 years of age)

Preoperational stage (2–7 years)

Concrete operational stage (8–12 years)

Formal operational stage (12–15 years)

By observing children’s play, Piaget demonstrated that, toward the end of the second year of life, a qualitatively new kind of psychological functioning occurs. In Piagetian theory, an operation is any procedure for mentally acting on objects. The preoperational stage consists of sparse and logically inadequate mental operations and is characterized by symbolic functioning, centration, intuitive thought, egocentrism (which is distinct from egoism), and the inability to conserve (see Box 1).

The transition from preoperational to operational functioning (in terms of Piaget) and perceived functionality instead of the experience of “It doesn’t matter what I do” is the goal of CBASP; it is therefore constructed to address two core problems in living which that ensue from these learned expectancies taught by the vicissitudes of life with others:

The pervasive fear-avoidance potential that typifies the way the persistently depressed person navigates through their life. Interpersonal involvement is often sought but cannot be tolerated. Wariness of others is central, with these fears of others being tacit or outside of awareness.

Perceptual disconnection or blindness to the impact of their actions on others. Persistently depressed people do not easily link their behavior with social consequences. They do not easily see “Because I did this, that happened.”

|14|Box 1.Piaget’s formulation of the preoperational state of development

Symbolic functioning

The use of mental symbols, words, or pictures to represent something that is not physically present.

Centration

Focusing or attending to only one aspect of a stimulus or situation. For example, when transferring liquid from a narrow beaker into a shallow dish, a preschool child might judge the quantity of liquid to have decreased, because its level is lower, i.e., the child focuses on the height of the water and fails to compensate the increase in the diameter of the container.

Intuitive thought

The child can believe in something without knowing why.

Egocentrism

A version of centration, this is the child’s tendency to think only from their own point of view and to be unable to take the point of view of others.

Inability to conserve

Lack perception of conservation of mass, volume, and number after the original form has changed.

Figure 1.  CBASP as a system.

Procedures

CBASP therapists endeavor to create a safe space where the patient can experience social interactions different from those experienced in their environment outside the clinical setting. And given the problems outlined above, this is no easy task. The therapist takes the time to come to know the person and to be aware of and prepared for any cryptic, submissive, hostile, or overly friendly interpersonal styles that in all likelihood will emerge as the core tasks in therapy. The therapist endeavors to choreograph the patient’s attention when they arise. CBASP therapists must be willing to take the time to coach |15|the patient to learn the skills necessary to move away from a mode of preoperational functioning to more often experience a state of perceived functionality. The person seeking help must come to know what the therapist knows regarding improving the skills necessary for managing mood dysregulation, improving relationships, acquiring the capacity for genuine empathy as opposed to interpersonal sensitivity, and recognizing their stimulus value when interacting with others. And, most importantly, they need to move toward these capacities without reference to the therapist, that is, outside the clinical setting in the real world where these new capacities have most healing power. When working with individuals with chronic depression, CBASP therapists are encouraged to “Let the patient do the work.” It is important to recognize that the person seeking help most likely finds it difficult to unequivocally accept that help. Poor concentration, lack of energy, concerns about making mistakes, the risk of revealing oneself to someone else, and communicating needs all become mixed up with a high degree of passivity and submissive tendencies. The CBASP therapist must inhibit the reflexive drive to take charge and become dominant. Passive–submissive individuals tend to pull such dominant take-charge behavior from others. Taking charge is, of course, important at times, but the therapist must be willing to take the patient along with them. Too much dominance has the reciprocal effect of actually pushing the individual further into the passive–submissive observer role, where they cannot easily learn what needs to be learned. The therapist must use their skill and large reserves of patience to facilitate the patient’s taking a participant role. This requires the therapist to slow things down and to not assume the patient is on the same page just because what has been explored seems obvious to them.

In the remainder of this section, we introduce the procedures and the timing of these activities within a course of CBASP. Of course, such timing and the overall time taken to complete each stage depends entirely on the capacity and needs of the person seeking help. We encourage CBASP therapists to try to adhere to the timings suggested as much as possible, albeit always in keeping with the patient’s capacities.

The phases of a course of CBASP are summarized below and have been compiled from the writings of McCullough and colleagues (McCullough, 2000, 2001, 2006; McCullough Jr. et al., 2015). Further details on these procedures are provided in the respective chapters (see Table 1).

Component 1: Assessment and Historical Perspective

The work associated with the first component of the CBASP takes place in the first four or five sessions.

Session 1: Timeline

The therapist guides the patient through the Timeline Exercise. The focus lies on going back in time to elucidate and track the severity of depressive experiences and symptoms |16|over the previous months and years. One target of this procedure is to highlight and link mood changes to triggers such as changes in the social environment with associated interpersonal and intrapersonal challenges and events. This exercise can be difficult for several reasons, the principal reason being memory difficulties, though it is possible to aid recall (explored in Chapter 4).

Gathering and exploring this information comprises confirming the diagnosis and subtype of chronic depression and establishing the age of onset of the person’s problems with their affective disorder. However, it also means garnering other information to aid in case formulation and to obtain a fuller picture of the individual. This information may include the nature of previous and current relationships, past and current adversity, and past and current traumata. The Timeline Exercise helps to gain insight into the activating and ameliorating factors that accompany the waxing and waning of persistent depressive symptoms over time. The hope is the patient comes to see that changes in mood states are not wholly autonomous; they do not happen in some sort of vacuum but are related to events usually social/interpersonal in nature. Time taken for the Timeline Exercise also provides the experience of the patient moving from the observer perspective to a more participant role in the initial stages of therapy.