Cognitive behavioural analysis system of psychotherapy

cognitive behaviouralcognitive behaviouralanalysis systemanalysis system

of psychotherapyof psychotherapy

personal backgroundpersonal background

to help people with psychological difficulties – to help people with psychological difficulties – typically adults with depression and/or anxiety typically adults with depression and/or anxiety when effective help is not readily available when effective help is not readily available elsewhere elsewhere

to try to provide & encourage a whole person to try to provide & encourage a whole person approach using what’s best in conventional, approach using what’s best in conventional, complementary, & self-help methods of health carecomplementary, & self-help methods of health care

work through a small charity whose aims are:

for more details & a downloadable copy of this talk go to the ‘goodknowledge’ section of www.goodmedicine.org.uk click on ‘lecturesand leaflets’ and look under ‘cbt, depression & ...’ in ‘past lectures’

why am I giving this why am I giving this talk?talk?

excited by how relevant excited by how relevant CBASP seems to be for CBASP seems to be for many patients that we many patients that we seesee

not an expert, simply an not an expert, simply an interested fellow travellerinterested fellow traveller

sharing enthusiasms is sharing enthusiasms is one of the best forms one of the best forms of self-education!of self-education!

key points of this key points of this talktalk

why take CBASP seriously?why take CBASP seriously? what does CBASP involve?what does CBASP involve? situational analysis (SA)situational analysis (SA) interpersonal discrimination interpersonal discrimination

exercise (IDE)exercise (IDE) psychotherapy depression psychotherapy depression

treatment developments treatment developments

major depression often major depression often persistspersists

50

63

7682

0

10

20

30

40

50

60

70

80

90

3 6 12 24

perc

enta

ge r

eco

vere

d

time from start of depressive episode

Spijker J. et al. Duration of major

depressive episodes in the

general population. Br J Psychiatry 2002;181:208-

213

dysthymic disorder is very dysthymic disorder is very commoncommon

Jonas, B. S., D. Brody, et al. (2003). Prevalence of mood disorders in a national sample of young American adults. Soc Psychiatry Psychiatr Epidemiol 38(11): 618-24.

lifetime prevalence in 7,667 young US adults (17-39) representative sample interviewed

1988-1994

6.2%6.2%

Beekman, A. T., D. J. Deeg, et al. (2004). Dysthymia in later life: a study in the community. J Affect Disord 81(3):

191-9.

current prevalence in 3,056 elderly Dutch adults (55-85); unfavourable prognosis

commented on4.6%4.6%

Steiner, M., B. Bell, et al. (1999). Prevalence of dysthymic disorder in primary care. J Affect Disord

54(3): 303-8.

12 month prevalence in 4,327 primary care Canadian adults; 90% had comorbid

disorders5.1%5.1%

cbasp for chronic cbasp for chronic depression depression

multisite trial involving 681 patients at 12 US academic centresmultisite trial involving 681 patients at 12 US academic centres aged 18-75, current major depressive disorder (MDD) with a aged 18-75, current major depressive disorder (MDD) with a

Hamilton Scale (HRSD-24) score > 19 and duration > 2 yearsHamilton Scale (HRSD-24) score > 19 and duration > 2 years either chronic MDD, or MDD superimposed on dysthymic either chronic MDD, or MDD superimposed on dysthymic

disorder, or recurrent MDD with incomplete remission between disorder, or recurrent MDD with incomplete remission between episodesepisodes

randomized to cognitive behavioral analysis system of psycho-randomized to cognitive behavioral analysis system of psycho-therapy (CBASP) or the antidepressant nefazodone or boththerapy (CBASP) or the antidepressant nefazodone or both

16-20 sessions over 12 weeks – a satisfactory response was 16-20 sessions over 12 weeks – a satisfactory response was defined as at least a 50% reduction in Hamilton Scale scoredefined as at least a 50% reduction in Hamilton Scale score

662 patients attended at least one session and 519 completed 662 patients attended at least one session and 519 completed treatment; 22% drop out rates similar across the three groupstreatment; 22% drop out rates similar across the three groups

Keller, M. B., McCullough, J.P. et al. Keller, M. B., McCullough, J.P. et al. A comparison of nefazodone, the cog-A comparison of nefazodone, the cog-nitive behavioral-analysis system of psychotherapy, & their combination for nitive behavioral-analysis system of psychotherapy, & their combination for the treatment of chronic depression.the treatment of chronic depression. N Engl J Med 2000; 342(20): 1462-70 N Engl J Med 2000; 342(20): 1462-70

response of all & of response of all & of completerscompleters

48

73

4852

85

55

0

20

40

60

80

100

all completers

cbasp combination nefazodone

%

resp

onse

response was defined as a reduction of at least 50% in the initial Hamilton Rating Scale for Depression (HRSD) score, and a final HRSD score of 15 or

less.

‘all’ represents the 662 patients who attended at least one treatment session; ‘completers’ represents the 519 patients who completed the full 12

week protocol.

remission of all & of remission of all & of completerscompleters

33

48

2924

42

22

0

10

20

30

40

50

60

all completers

cbasp combination nefazodone

%

rem

issi

on

remission was defined as an HSRD score of 8 or less when they left the trial for those who didn’t complete the 12 week protocol or at both weeks 10 &

12 for those who did.

non-responders to single modality treatments (cbasp or nefazodone on their own) were later crossed over to the alternative single modality treatment, while responders were entered into maintenance treatment trials for both

cbasp and for nefazodone.

plethora of further papers plethora of further papers published published Arnow, B. A., R. Manber, et al. (2003). "Therapeutic reactance as a predictor of outcome in the Arnow, B. A., R. Manber, et al. (2003). "Therapeutic reactance as a predictor of outcome in the

treatment of chronic depression." treatment of chronic depression." J Consult Clin PsycholJ Consult Clin Psychol 7171(6): 1025-35.(6): 1025-35. Gelenberg, A. J., M. H. Trivedi, et al. (2003). "Randomized, placebo-controlled trial of nefazodone Gelenberg, A. J., M. H. Trivedi, et al. (2003). "Randomized, placebo-controlled trial of nefazodone

maintenance treatment in preventing recurrence in chronic depression." maintenance treatment in preventing recurrence in chronic depression." Biol PsychiatryBiol Psychiatry 5454(8): (8): 806-17.806-17.

Hirschfeld, R. M., D. L. Dunner, et al. (2002). "Does psychosocial functioning improve independent Hirschfeld, R. M., D. L. Dunner, et al. (2002). "Does psychosocial functioning improve independent of depressive symptoms? A comparison of nefazodone, psychotherapy, and their combination." of depressive symptoms? A comparison of nefazodone, psychotherapy, and their combination." Biol PsychiatryBiol Psychiatry 5151(2): 123-33.(2): 123-33.

Klein, D. N., N. J. Santiago, et al. (2004). "Cognitive-behavioral analysis system of psychotherapy Klein, D. N., N. J. Santiago, et al. (2004). "Cognitive-behavioral analysis system of psychotherapy as a maintenance treatment for chronic depression." as a maintenance treatment for chronic depression." J Consult Clin PsycholJ Consult Clin Psychol 7272(4): 681-8.(4): 681-8.

Klein, D. N., J. E. Schwartz, et al. (2003). "Therapeutic alliance in depression treatment: Klein, D. N., J. E. Schwartz, et al. (2003). "Therapeutic alliance in depression treatment: controlling for prior change and patient characteristics." controlling for prior change and patient characteristics." J Consult Clin PsycholJ Consult Clin Psychol 7171(6): 997-(6): 997-1006.1006.

Manber, R., B. Arnow, et al. (2003). "Patient's therapeutic skill acquisition and response to Manber, R., B. Arnow, et al. (2003). "Patient's therapeutic skill acquisition and response to psychotherapy, alone or in combination with medication." psychotherapy, alone or in combination with medication." Psychol MedPsychol Med 3333(4): 693-702.(4): 693-702.

Manber, R., A. J. Rush, et al. (2003). "The effects of psychotherapy, nefazodone, and their combin- Manber, R., A. J. Rush, et al. (2003). "The effects of psychotherapy, nefazodone, and their combination on subjective assessment of disturbed sleep in chronic depression." ation on subjective assessment of disturbed sleep in chronic depression." SleepSleep 2626(2): 130-6.(2): 130-6.

Nemeroff, C. B., C. M. Heim, et al. (2003). "Differential responses to psychotherapy versus Nemeroff, C. B., C. M. Heim, et al. (2003). "Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma." pharmacotherapy in patients with chronic forms of major depression and childhood trauma." Proc Natl Acad Sci U S AProc Natl Acad Sci U S A 100100(24): 14293-6.(24): 14293-6.

Ninan, P. T., A. J. Rush, et al. (2002). "Symptomatic and syndromal anxiety in chronic forms of Ninan, P. T., A. J. Rush, et al. (2002). "Symptomatic and syndromal anxiety in chronic forms of major depression: effect of nefazodone, cognitive behavioral analysis system of psychotherapy, major depression: effect of nefazodone, cognitive behavioral analysis system of psychotherapy, and their combination." and their combination." J Clin PsychiatryJ Clin Psychiatry 6363(5): 434-41.(5): 434-41.

Schatzberg, A. F., A. J. Rush, et al. (2005). "Chronic depression: medication (nefazodone) or Schatzberg, A. F., A. J. Rush, et al. (2005). "Chronic depression: medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not." psychotherapy (CBASP) is effective when the other is not." Arch Gen PsychiatryArch Gen Psychiatry 6262(5): 513-20.(5): 513-20.

Thase, M. E., A. J. Rush, et al. (2002). "Differential effects of nefazodone and cognitive behavioral Thase, M. E., A. J. Rush, et al. (2002). "Differential effects of nefazodone and cognitive behavioral analysis system of psychotherapy on insomnia associated with chronic forms of major analysis system of psychotherapy on insomnia associated with chronic forms of major depression." depression." J Clin PsychiatryJ Clin Psychiatry 6363(6): 493-500.(6): 493-500.

Zajecka, J., D. L. Dunner, et al. (2002). "Sexual function & satisfaction in the treatment of chronic Zajecka, J., D. L. Dunner, et al. (2002). "Sexual function & satisfaction in the treatment of chronic major depression with nefazodone, psychotherapy, and their combination." major depression with nefazodone, psychotherapy, and their combination." J Clin PsychiatryJ Clin Psychiatry 6363(8): 709-16. (8): 709-16.

highlights include ...highlights include ...

Schatzberg, A., A. Rush, et al. (2005). "Chronic depression: medication Schatzberg, A., A. Rush, et al. (2005). "Chronic depression: medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not." (nefazodone) or psychotherapy (CBASP) is effective when the other is not." Arch Arch

Gen PsychiatryGen Psychiatry 6262: 513-20.: 513-20.

Klein, D. N., J. E. Schwartz, et al. (2003). "Therapeutic alliance in depression Klein, D. N., J. E. Schwartz, et al. (2003). "Therapeutic alliance in depression treatment: con-trolling for prior change and patient characteristics." treatment: con-trolling for prior change and patient characteristics." J Consult Clin J Consult Clin

PsycholPsychol 7171(6): 997-1006.(6): 997-1006.

Early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone.

Among chronically depressed individuals, CBASP appears to be efficacious for nonresponders to nefazodone, and nefazodone appears to be effective for CBASP nonresponders. A switch from an antidepressant medication to psychotherapy or vice versa appears to be useful for nonresponders to the initial treatment.

& more highlights ...& more highlights ...

Klein, D. N., N. J. Santiago, et al. (2004). "Cognitive-behavioral analysis system of Klein, D. N., N. J. Santiago, et al. (2004). "Cognitive-behavioral analysis system of psycho-therapy as a maintenance treatment for chronic depression." psycho-therapy as a maintenance treatment for chronic depression." J Consult Clin J Consult Clin

PsycholPsychol 7272: 681-8. : 681-8.

Nemeroff, C. B., C. M. Heim, et al. (2003). "Differential responses to Nemeroff, C. B., C. M. Heim, et al. (2003). "Differential responses to psycho-therapy versus pharmacotherapy in patients with chronic forms of psycho-therapy versus pharmacotherapy in patients with chronic forms of

major depression and childhood trauma." major depression and childhood trauma." Proc Natl Acad Sci U S AProc Natl Acad Sci U S A 100100(24): 14293-6.(24): 14293-6.

Among those with a history of early childhood trauma (loss of parents at an early age, physical or sexual abuse, or neglect), psychotherapy alone was superior to antidepressant monotherapy. Moreover, the combination of psychotherapy and pharmacotherapy was only margin-ally superior to psychotherapy alone among the child abuse cohort.

Eighty-two patients who had responded to acute and continuation phase CBASP were randomized to monthly CBASP or assessment only for 1 year. Significantly fewer patients in the CBASP than assess-ment only condition experienced a recurrence. The 2 conditions also differed significantly on change in depressive symptoms over time.

cbasp & medication current cbasp & medication current winner winner

based on best current research the based on best current research the combination of CBASP and an anti-combination of CBASP and an anti-depressant is the evidence-based depressant is the evidence-based treatment for persistent depressiontreatment for persistent depression

NIMH began a further large multi- centre NIMH began a further large multi- centre trial in 2002 to explore the value of trial in 2002 to explore the value of adding CBASP – or a control adding CBASP – or a control psychotherapy – when persistent psychotherapy – when persistent depression sufferers failed to respond depression sufferers failed to respond adequately to an antidepressantadequately to an antidepressant

due to report in march ‘06due to report in march ‘06the largest ever randomized psychotherapy-medication depression treatment trial – a 9

site, 4 (+ 2) year study – is due to report results in 2006

910 chronically depressed outpatients wereentered into a 12 week antidepressant trial

non & partial responders then had their antidepressant changed or augmented for 12

weeks & were randomized to one of three possible groups

1.) medication on its own2.) medication plus Brief Supportive

Psychotherapy3.) medication plus CBASP


why take CBASP seriously?why take CBASP seriously? what does CBASP involvewhat does CBASP involve?? situational analysis (SA)situational analysis (SA) interpersonal discrimination interpersonal discrimination



some characteristics of some characteristics of cbasp cbasp

cbasp aims to tackle the sense of powerlessness cbasp aims to tackle the sense of powerlessness and tendency to overgeneralize that are postulated and tendency to overgeneralize that are postulated to be of crucial importance in chronic depression to be of crucial importance in chronic depression

the core technique is teaching ‘situational analysis’ the core technique is teaching ‘situational analysis’ to help sufferers tackle interpersonal problems more to help sufferers tackle interpersonal problems more effectively & improve their sense of personal controleffectively & improve their sense of personal control

the therapeutic relationship itself is also used the therapeutic relationship itself is also used actively to modify sufferers preconceptionsactively to modify sufferers preconceptions

see handouts: ‘coping survey questionnaire’ used in see handouts: ‘coping survey questionnaire’ used in ‘situational analysis’ and ‘significant others’ list & ‘situational analysis’ and ‘significant others’ list & grid used in the ‘interpersonal discrimination grid used in the ‘interpersonal discrimination exercise’ exercise’





SA:SA: situational analysissituational analysis it’s possible to conceptualise what’s happening in it’s possible to conceptualise what’s happening in

situational analysis in a number of overlapping wayssituational analysis in a number of overlapping ways at its simplest, one can see SA as a methodical way at its simplest, one can see SA as a methodical way

of teaching better interpersonal problem solving skillsof teaching better interpersonal problem solving skills we know that depression sufferers tend to over-we know that depression sufferers tend to over-

generalise & feel helpless/hopeless. SA can also be generalise & feel helpless/hopeless. SA can also be seen as an effective way of combating these vulner-seen as an effective way of combating these vulner-abilities – and there is research showing increases in abilities – and there is research showing increases in internalized locus of control with CBASP treatmentinternalized locus of control with CBASP treatment

James McCullough himself talks, on his website, about James McCullough himself talks, on his website, about helping chronic depression sufferers ‘mature’ in their helping chronic depression sufferers ‘mature’ in their appreciation of the way they affect other’s responses appreciation of the way they affect other’s responses and resultant interpersonal outcomesand resultant interpersonal outcomes

SA:SA: coping survey coping survey questionnairequestionnaire the ‘coping survey questionnaire’ is used repeatedly the ‘coping survey questionnaire’ is used repeatedly

over the course of CBASP treatmentover the course of CBASP treatment the explicit treatment goal is not so much to help the explicit treatment goal is not so much to help

patients solve particular interpersonal problems as to patients solve particular interpersonal problems as to teach them to approach all such problems in a new teach them to approach all such problems in a new wayway

interestingly this emphasis on the crucial importance interestingly this emphasis on the crucial importance of changing attitude (more internalized control/choice) of changing attitude (more internalized control/choice) is backed up by other research on teaching more is backed up by other research on teaching more general problem solving skills to depression sufferersgeneral problem solving skills to depression sufferers

there are also fascinating overlaps between this there are also fascinating overlaps between this approach and Behavioural Activation (BA), Acceptance approach and Behavioural Activation (BA), Acceptance & Commitment Therapy (ACT), Task Concentration & Commitment Therapy (ACT), Task Concentration Training & Mindfulness Based Cognitive Therapy Training & Mindfulness Based Cognitive Therapy (MBCT)(MBCT)

SA:SA: using the questionnaireusing the questionnaire the patient completes one or possibly two the patient completes one or possibly two

questionnaires each week & brings them to the questionnaires each week & brings them to the weekly therapy sessionweekly therapy session

a considerable amount of therapeutic time is spent a considerable amount of therapeutic time is spent going through the questionnaires with the patientgoing through the questionnaires with the patient

the overall goal is spelled out clearly – ‘that patients the overall goal is spelled out clearly – ‘that patients ‘must learn to do each of the SA steps by themselves ‘must learn to do each of the SA steps by themselves and without assistance from the clinician’ and without assistance from the clinician’

McCullough repeatedly underlines the importance of McCullough repeatedly underlines the importance of ‘getting the patient to do the work’; he claims that a ‘getting the patient to do the work’; he claims that a dominant, take-charge style is ‘therapeutically lethal’ dominant, take-charge style is ‘therapeutically lethal’ for these helpless/hopeless depression sufferers for these helpless/hopeless depression sufferers

let’s try it ... with a personal or patient’s examplelet’s try it ... with a personal or patient’s example





IDE:IDE: interpersonal interpersonal discriminationdiscrimination

it is assumed that experiences in important early it is assumed that experiences in important early relationships will contribute to difficulties in current relationships will contribute to difficulties in current and future important/close relationshipsand future important/close relationships

it is also predicted that many of these difficulties are it is also predicted that many of these difficulties are likely to emerge in the therapeutic relationshiplikely to emerge in the therapeutic relationship

rather than seeing such difficulties as a therapeutic rather than seeing such difficulties as a therapeutic problem, the interpersonal discrimination exercise problem, the interpersonal discrimination exercise (IDE) aims to turn them into ‘behavioural (IDE) aims to turn them into ‘behavioural experiments’experiments’

so the therapeutic relationship is used actively to so the therapeutic relationship is used actively to help sufferers challenge & update dysfunctional early help sufferers challenge & update dysfunctional early beliefsbeliefs

IDE:IDE: the significant others the significant others listlist

early in treatment – usually at the early in treatment – usually at the 2nd session – the sufferer makes a 2nd session – the sufferer makes a list of up to seven people who have list of up to seven people who have had most influence on them and their had most influence on them and their lifelife

this influence might be positive or this influence might be positive or negative, but it seems a major factor negative, but it seems a major factor in the direction their life has taken, in the direction their life has taken, the kind of person they are, & how the kind of person they are, & how they feel, think, behave & relate they feel, think, behave & relate

the therapist is urged to interrupt the therapist is urged to interrupt ‘story telling’ & help the sufferer ‘story telling’ & help the sufferer make the cause-effect links for make the cause-effect links for themselvesthemselves

IDE:IDE: the significant others the significant others gridgrid

one (or possibly two) ‘transference one (or possibly two) ‘transference hypotheses’ are then constructed to hypotheses’ are then constructed to highlight particularly relevant and highlight particularly relevant and destructive interpersonal themesdestructive interpersonal themes

these ‘hypotheses’ are focused on these ‘hypotheses’ are focused on one (or more) of four pre-selected one (or more) of four pre-selected domains: intimacy, failure, need, & domains: intimacy, failure, need, & confrontation confrontation

these four interpersonal domains are these four interpersonal domains are targeted as they are considered to targeted as they are considered to reflect common interpersonal experi-reflect common interpersonal experi-ences encountered in psychotherapyences encountered in psychotherapy

IDE:IDE: the significant others the significant others gridgrid

1.1. moments of intimacy when the patient opens moments of intimacy when the patient opens up emotionally to the therapist up emotionally to the therapist

2.2. when the patient makes a mistake or fails in when the patient makes a mistake or fails in some observable way some observable way

3.3. times when the patient expresses felt times when the patient expresses felt emotional needs to the therapistemotional needs to the therapist

4.4. when the patient expresses some negative when the patient expresses some negative affect toward the therapist either verbally or affect toward the therapist either verbally or nonverbally (e.g. frustration, anger, shame, nonverbally (e.g. frustration, anger, shame, guilt, sexual affect if it carries a negative guilt, sexual affect if it carries a negative connotation, etc.). connotation, etc.).

the four interpersonal domains targeted in the the four interpersonal domains targeted in the IDE:IDE:

using the transference using the transference hypothesishypothesis

the IDE is used proactively whenever the the IDE is used proactively whenever the patient-therapist encounter moves into patient-therapist encounter moves into the targeted “hot spot” transference areathe targeted “hot spot” transference area

the patient is encouraged to compare & the patient is encouraged to compare & contrast the therapist’s behaviours in the contrast the therapist’s behaviours in the targeted interpersonal domain with those targeted interpersonal domain with those of maltreating significant others.of maltreating significant others.

once the discrimination is made explicit, once the discrimination is made explicit, patients are then taught how to function patients are then taught how to function in the new interpersonal reality existing in the new interpersonal reality existing between himself/herself and the clinician.between himself/herself and the clinician.




treatment developmentstreatment developments

cbt treatment developments cbt treatment developments & improving treatment of & improving treatment of

depressiondepressionCognitive Behaviour Analysis System of Cognitive Behaviour Analysis System of

Psychotherapy (CBASP)Psychotherapy (CBASP)Contextual Behavioural Activation (BA)Contextual Behavioural Activation (BA)Mindfulness Based Cognitive Therapy (MBCT)Mindfulness Based Cognitive Therapy (MBCT)Other form of Attention Training (Bogels, Wells)Other form of Attention Training (Bogels, Wells)Acceptance and Commitment Therapy (ACT)Acceptance and Commitment Therapy (ACT)NICE & PTSD, and the commonness of NICE & PTSD, and the commonness of

traumatic imagery across depression & anxietytraumatic imagery across depression & anxiety

james mcullough cbasp james mcullough cbasp resourcesresources

McCullough, J.P. McCullough, J.P. Treatment for chronic depression. Treatment for chronic depression. New York: Guilford Press, 2000New York: Guilford Press, 2000

McCullough, J.P. McCullough, J.P. Skills training manual for Skills training manual for diagnosing & treating chronic depression. diagnosing & treating chronic depression. New New York: Guilford, 2001York: Guilford, 2001

McCullough, J.P. McCullough, J.P. Patient’s manual for CBASP Patient’s manual for CBASP New New York: Guilford Press, 2003York: Guilford Press, 2003

... and McCullough, J.P. ... and McCullough, J.P. Treating chronic depression Treating chronic depression with disciplined personal involvement: CBASP with disciplined personal involvement: CBASP New York: Springer Press, due out July, 2006)New York: Springer Press, due out July, 2006)

Website with course & other details: Website with course & other details: www.cbasp.orgwww.cbasp.org

to download a copy of this to download a copy of this talk talk

for more details and a download-able copy of this talk go to the “good knowledge” section of www.goodmedicine.org.uk , click on “lectures and leaflets” & look under “cbt, depression & problem solving” in “past lectures”

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Cognitive behavioural analysis system of psychotherapy