CBASP - ukpts

Cognitive Behavioural Analysis
System of Psychotherapy (CBASP):
developed for chronic depression
adaptable for chronic posttraumatic reactions
Alastair Hull & John Swan
NHS Tayside & University of Dundee
UKPTS, Third Annual Conference, 2011
CBASP
Synopsis & housekeeping
• Overview of CBASP
• Its background & the model
• Overview of trauma & its interface with depression
• Very briefly early research findings on CBASP
• Using CBASP with traumatised individuals
• Break
• Pre-break and post-break agenda
• Certificate of attendance (for ESTSS certificate)
CBASP
Background
• CBASP developed as a treatment for chronic
depression
• may be especially effective for chronic depression
on a background of childhood trauma
Importance of Trauma

Association between CSA and depression
(for example, Cheasty et al, 1998; Spataro et al,
2004)

often within a matrix of disadvantage
Importance of Trauma

Association between CSA and depression
(for example, Cheasty et al, 1998; Spataro et al,
2004)


often within a matrix of disadvantage
CSA especially common in 3-4 years before
puberty (Mullen et al, 1994)
 critical period for personal and social
development
Importance of Trauma



Association between CSA and
depression
CSA especially common in 3-4 years
before puberty
after childhood trauma
 risk of depression equal to risk of
PTSD up until 13years.
 after 13 years risk of PTSD is greater
Maercker et al, 2004
Importance of Trauma

patients with chronic depression

a history of early life trauma predicts the need
for psychotherapy as an adjunct to medication
(CBASP: Nemeroff et al, 2003)
Importance of Trauma

patients with chronic depression


a history of early life trauma predicts the need
for psychotherapy as an adjunct to
pharmacotherapy (CBASP: Nemeroff et al, 2003)
high percentage of patients with bipolar
disorder have a history of childhood
deprivation or abuse (50%; Garno et al, 2005)
Psychological reactions after trauma
For example,

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Depression
Grief Reaction
Panic Attacks +/- agoraphobia
Alcohol/Drug Dependence
Brief Hypomania
Specific Phobias (e.g., travel)
PTSD
Trauma - background
•
•
index trauma often on complex
background of vulnerability ( & resilience)
factors
these may include:
 childhood neglect, abuse or loss
 dysthymia
 other adult trauma
Significant others: the
interpersonal perspective
•
in many cases the people who are closest are
the perpetrators of the traumatic acts
Significant others: the
interpersonal perspective
•
•
in many cases the people who are closest are
the perpetrators of the traumatic acts
this is an extremely complex situation
Significant others: the
interpersonal perspective
•
•
•
in many cases the people who are closest are
the perpetrators of the traumatic acts
this is an extremely complex situation
the result is an attachment to the abusing
person- a phenomenon known as “traumabonding”
Trauma-bonding
•
•
•
•
in many cases the people who are closest are
the perpetrators of the traumatic acts
this is an extremely complex situation
the result is an attachment to the abusing
person- a phenomenon known as “traumabonding”
as a result, highly destructive and untrustworthy
relationships come to be considered normal
(van der Kolk, 1989; Herman, 1992)
Trauma-bonding
•
•
•
•
in many cases the people who are closest are
the perpetrators of the traumatic acts
this is an extremely complex situation
the result is an attachment to the abusing
person- a phenomenon known as “traumabonding”
as a result, highly destructive and untrustworthy
relationships come to be considered normal
(van der Kolk, 1989; Herman, 1992)
•
innate protective mechanisms get turned upside
down with persecutors also providing
intermittent nurturance
Social skills and traumatised
individuals
•
individuals traumatised in childhood often have
severely incapacitated ability to get along with
people
Social skills and traumatised
individuals
•
•
individuals traumatised in childhood often have
severely incapacitated ability to get along with
people
they know the parameters of abusive
relationships
•
these relationships are experienced as predictable
Social skills and traumatised
individuals
•
•
individuals traumatised in childhood often have
severely incapacitated ability to get along with
people
they know the parameters of abusive
relationships
•
•
these relationships are experienced as predictable
non-abusive relationships are anxiety producing,
frightening and unpredictable
•
leads to behaviours provoking others to act in
predictable and familiar ways
Social skills and traumatised
individuals
•
•
individuals traumatised in childhood often have
severely incapacitated ability to get along with
people
they know the parameters of abusive
relationships
•
•
•
these relationships are experienced as predictable
non-abusive relationships are anxiety producing,
frightening and unpredictable
response on the part of others (including
therapists) is predictable•
i.e., “they don‟t want help, they are resistant”
CBASP model for Treatment
of chronic depression
Cognitive Behavioural Analysis
System of Psychotherapy - CBASP
CBASP overview (i)
CBASP is composed of several novel elements:
Assessment and pre-treatment work
 Establishing the diagnosis
 Timeline

Potential problems in the relationship
 Significant Other History (SOH)
 Impact Message Inventory (IMI)
 Transference Hypothesis (TH)
CBASP overview (ii)

Dealing with the chronically depressed
person‟s inability to perform formal operations

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Situational Analysis (SA)
A group of “in-the-room therapy skills” which
address the interpersonal challenge of working
with people with chronic depression

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Interpersonal Discrimination Exercise (IDE)
Contingent Personal Responsivity (CPR)
CBASP overview (iii)

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Need to deal with each in turn by
demonstration, practice and feedback
Make links between the components
Time to give a taster but will concentrate
upon SA as 70% of sessions
The problem….

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Data on how best to proceed with chronic depression
is lacking (Stimpson, 2000)
Clinical experience shows that standard CBT is very
difficult with this population
Undoubtedly need very experienced CBT practitioners
and these are “thin on the ground”
Variants of CBT needed…. MBCT and Behavioural
Activation... but…..
Potential solution…..?

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Cognitive Behavioural Analysis System of
Psychotherapy (CBASP)
Specifically formulated for chronic depression
Series of publications of a large multi-centre trial
since 2000
Central publication is in The New England Journal
of Medicine, volume 342(20) 2000: 1462-1470
[Keller, McCullough, Klein et al]
Series of publications of a large multi-centre trial
(Hirschfield et al, 2002; Nemeroff et al, 2003; Arnow et al ,
2003 & Schatzberg et al, 2005) (n=681)
CBASP Research –
general findings
3 treatment groups
(no placebo)
 CBASP alone
 Nefazodone alone
 Combination of 1 & 2

681 adults randomised
(519 completed)
% improved using HAMD

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Combination 73%
CBASP alone 48%
Nefazodone alone 48%
The evidence
Results
 Combined had significant greater effect upon
psychosocial improvement than either alone

CBASP had an effect upon psychosocial function
relatively independent of symptom change
 i.e., change in depressive symptoms does not fully
explain psychosocial improvement
CBASP findings re trauma
Very high prevalence rate of early life trauma
in people with chronic depression
 65% had experience of “trauma” 65%
 1/3 experienced parental loss before age 15 years
 45% experienced childhood physical abuse
 16% experienced CSA
 10% experienced neglect
 # trauma types: 1 (37%) 2 (18%) 3 (8%) 4 (2%)
Nemeroff et al, 2003
CBASP study- findings
For individuals with early life trauma
 CBASP (with or without medication) was
superior to medication alone
Nemeroff et al, 2003
CBASP study- findings
For individuals with early life trauma
 CBASP (with or without medication) was
superior to medication alone
 persisted when controlled for gender, age,
race and depression severity
Nemeroff et al, 2003
CBASP study- findings
For individuals with early life trauma
 CBASP (with or without medication) was
superior to medication alone
 persisted when controlled for gender, age,
race and depression severity
 likelihood of remission x2 with CBASP
(odds ratio = 2.3)
Nemeroff et al, 2003
CBASP - response
Chronic depression without
childhood trauma (n=181)
Chronic depression with
childhood trauma (n=325)
CBASP – remission rates
Chronic depression without
childhood trauma (n=181)
Chronic depression with
childhood trauma (n=325)
Promising…..
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Keller‟s study produced impressive results in a very difficult
to treat population
Text books……..intriguing!….complicated!
Next steps?..... Get some CBASP “buddies” and work on
it……. (we‟ve been working on it for 6-7 years now!)
Get in touch with “The Master” and off to Richmond,
Virginia USA for 10 days! (that was 5 years ago!) or….. we
have ran some 3 day intensive workshops
The Master……


James P.
McCullough, Jnr
Virginia
Commonwealth
University,
Richmond,
Virginia USA.
Case histories…..
Case 1
 56 year old combat veteran (Falklands war). Emotionally
deprived childhood, adult trauma, chronic depression,
chronic complex treatment resistant PTSD
Case 2
 33 year old mother of 5. Childhood deprivation, neglect
and sexual abuse, abusive adult relationships, chronic
depression, some post-trauma symptoms, prominent fear.
Case 3
 40 year old unemployed mother of 2. Childhood
psychological abuse, adult trauma, chronic treatment
resistant depression, sub-syndromal PTSD, family issues.
CBASP – the model


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To date, the only therapy designed specifically
to treat chronic depressive disorders
Arrested maturational development is viewed as
the aetiological basis of chronic depression
“Person x environment” focus and teaching
person their “stimulus value” within that
environment
Person x Environment interactions
where emotional change is possible
Situational context
i.e., the environment
Cognitive connection
with situation
Physiological reactivity
Situation-directed
behaviour
Preoperational disconnection with the
environment where emotional change
is precluded
Situational context
i.e., the environment
On going effects of
depression
Cognitive disconnection
with situation
Non-situation-directed
behaviour
Early adverse
events
Physiological reactivity
CBASP aims to change this barrier to
feedback from the situational context

Hard to maintain fiction that it doesn‟t matter you do when looking
at the consequences of what you do i.e., consequate the behaviour
in the IDE
Situational context
i.e., the environment
Cognitive connection
with situation
Situation-directed
behaviour
Physiological reactivity
CBASP- the model (ii)

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Teach “Piagetian formal operations problems solving”
and empathic responsivity in conduct of social
interactions
Therapists have “disciplined” personal involvement
with patients to modify behaviour through use of
Interpersonal Discriminatory Exercise and Contingent
Personal Responsivity
Transference issues made explicit PRIOR to therapy
through Significant Other History and proactively
challenged throughout therapy whenever arise
CBASP – vehicles for change

Main therapy technique is Situational Analysis which is
used to exacerbate psychopathology in session

Negative reinforcement methodology is viewed as the
essential motivational strategy

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Teach a range of techniques designed to facilitate
behavioural change and move from “Actual Outcomes”
to “Desired Outcomes”
Interpersonal Domain: Transference Hypothesis;
Interpersonal Discrimination Exercise and Disciplined
Personal Involvement
CBASP – the model (iii)

In a sense the actual therapy becomes the strategies
familiar in CBT such as assertiveness, problem solving,
modelling etc……. Repeat ++

CBASP therapists need to be willing to use the
relationship and accept the “white knuckle ride”

CBASP therapists need to be willing to “go back and
get the patient”

CBASP therapists need to be willing to take control of
sessions
Timeline and Diagnosis:
Has the patient got Chronic
Depression?
Timeline
Next …. Significant Other History
and Transference Hypothesis
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Take a significant other history
Construct transference hypothesis
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Reflect on Impact Message Inventory
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Forewarned is forearmed….
Forewarned is forearmed….
Expect “hotspots”
Use these strategically and carefully
CBASP looks towards Disciplined Personal Involvement
 Contingent Personal Responsivity
 Interpersonal Discrimination Exercise
Constructing the
Transference Hypotheses
Significant other history

Patient lists up to 7 significant others who
have been influential in shaping the course
of their lives and the nature of their
relationships

Patient is asked to make causal
connections between their relationship
with each of these significant others and
the effect this has had on their own lives
Constructing the
Transference Hypotheses
(continued)
Therapist guides the patient to
construct causal theory conclusions
about each person on the list
Commonly

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
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
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Intimacy/closeness
Expressing or disclosing a particular
emotional need or problem
Failing or making mistakes
Expressing or acting out negative affect
Constructing the Transference
Hypotheses (continued)

For example, a causal theory conclusion
around the theme of intimacy/closeness:

Father: He was disinterested in me and rarely
spent time with me.

The “stamp” or causal theory conclusion for
father was: “People and relationships are difficult
and hurtful, so it is best to keep to yourself.”

Transference hypotheses constructed in
relation to most prominent of the 4 domains
Constructing the Transference
Hypotheses (continued)

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The transference hypothesis refers specifically
to what the patient – implicitly or explicitly –
believes will happen to him/her with the
therapist
An example of a transference hypothesis
around the theme of intimacy/closeness would
be:
“If I let X know how I feel (about anything) then he
will punish or ridicule me”
Impact Message Inventory

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A self-report measure of the interpersonal
style of the patient (Kiesler, 1996) -completed
by the therapist
Describes the interpersonal style of the
patient so that the characteristic „pulls and
tugs‟ on the therapist can be identified and
inhibited

These are mainly pulls for dominant and
hostile reactions to submissive and hostile
behaviour
Affiliative Dimension
HOSTILE
“You annoy me,
stay away from me”
FRIENDLY
“I like you and
want to help”
Power Dimension
DOMINANT
“Do what I say and you’ll be okay”
SUBMISSIVE
“I’ll do anything you say, just
take care of me”
Kiesler‟s Interpersonal Circle
Why is this therapeutic?
“When practitioners do not react in
complementary or corresponding
ways (similar to the way other people
typically react to them), patients are
automatically thrown into unfamiliar
interpersonal territory.…this may
produce momentary discomfort but over time – offers patients
opportunities to learn novel
interpersonal patterns”
(McCullough, 2001, p. 150)
Impact Message Inventory
Complete an IMI on a chronically
depressed patient you know well
OR
On a close friend
OR
Your boss
…and then reflect on your relationship with them
…..and then reflect on what you learned?
…..any “lightbulb” moments?
The interpersonal
aspects of CBASP
The Interpersonal Aspect of
CBASP (i)

Psychopathology = rigidity in cognitive and behavioural
repertoires

The patients bring their chronic depression into the room

Two person psychology

Rigid cognitive and behavioural repertoires play out
between therapist and patient
The Interpersonal Aspect of
CBASP (ii)

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Disconnection
Choreographing/focussing patient‟s attention on
consequences of rigid thoughts and behaviours
The therapist becomes an “interpersonal obstruction”
when required
This can be challenging and different from standard
models
The Interpersonal Aspect of
CBASP (iii)

Specific procedures are IDE and CPR

Judicious use

Within context of an established relationship

This can moderate cryptic/hostile/submissive
interpersonal styles over time
Mr. Nice and Mr. Hostile

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DVD… Mr. Nice
DVD….Mr Hostile
Disciplined Personal Involvement
Adds several challenging elements to
the collaborative therapeutic
relationship sought in CBT:


channel by which hurtful past emotional
experience can be healed (IDE)
channel by which the patient becomes more
aware of the negative interpersonal
consequences of their behaviour (CPR)
Sources of Information for
DPI
Mr Nice as Case Study
 Male, mid 30s, gay, artist.
 Has had depression since mid teens
 Treated over the years with CBT,
medication, in-patient stays, ECT
 Is not in a relationship at present
Sources of Information for DPI

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Family are very supportive
Experiences mum as over involved
Father very critical of pts life style and job.
Brother „has done things the right way‟.
Pt has a sense that his friends and family
just „suffer him‟.
Sources of Information for DPI

Pt voices global defeatist thoughts, e.g.
„I‟m just a hopeless case‟
„Nothing I try ever works‟
„I‟ve tried everything to make me feel
better‟
„I just get on people‟s nerves‟
Preparatory work for the IDE
Therapist draws on 3 sources of
information

Significant Other History

Transference hypotheses
developed by the therapist during
second and third session

Impact Message Inventory (IMI)
Significant Other History
Significant Other History
Mum
„Life is difficult – I can‟t get it right‟
Dad
„Other people think am not good enough‟
School friend (S2)
„I‟m embarrassed about who I am‟
Brother
„I can‟t live up to people‟s expectations‟
Friend (since P1)
„I can be myself‟
First partner
„I don‟t know what I want in close
relationships‟
Transference Hypothesis
„If I tell Marianne who I really am, she won‟t
like me and criticise or reject me‟
Impact Message Inventory
D
4
DH
3
FD
2
1
H
0
F
HS
FS
S
Background to the IDE

Early life experiences of chronically
depressed patients - neglect, abuse,
indifference - give rise to global
expectations of similar treatment from
others, including therapists
“The way things were for me in the past
is the way things will be for me here”
The IDE procedure
Therapist


Highlights the hotspot and describes it
Then asks patient a series of questions:





“How would „significant other‟ have behaved in a
similar situation to this?”
“What was my reaction to you when you said this
to me?”
“How do our reactions compare?”
How does what has just happened affect our
relationship?”
Then helps patient to identify facilitative
individuals outside the therapy situation
IDE goal
Discriminate between:
experiences with therapist =/= experience with significant
others
Why is the IDE effective?


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It highlights interpersonal behavioural
consequences
It teaches formal operations thinking
It enhances motivation for change
It teaches appropriate interpersonal
expectancies and behaviours
Key points


Trauma and depression are closely linked
Early evidence would suggest CBASP may be
better than medication for depression where
there is early life trauma
Key points



Trauma and depression are closely linked
Early evidence would suggest CBASP may be
better than medication for depression where
there is early life trauma
Anchoring the therapy at a specific point may
be key
Key points




Trauma and depression are closely linked
Early evidence would suggest CBASP may be
better than pharmacological treatments for
depression where there is early life trauma
Anchoring the therapy at a specific point may
be key
CBASP may also represent an effective
approach with individuals with adult trauma
with co-morbid depression & PTSD
Key points





Trauma and depression are closely linked
Early evidence would suggest CBASP may be
better than pharmacological treatments for
depression where there is early life trauma
Anchoring the therapy at a specific point may
be key
CBASP may also represent an effective
approach with individuals with adult trauma
with comorbid depression & PTSD
Given the overlap of symptoms CBASP also
appears effective for PTSD itself….but empirical
evidence lacking to date
“staying in the slice”
Trauma focused-CBT or EMDR for PTSD
• advantage of being anchored in time to
the traumatic event
CBASP for Chronic Depression
• achieves this by using the vehicle of the
Situational Analysis
AVAILABLE CBASP BOOKS
McCullough, Jr., J.P. (2000).Treatment for Chronic Depression: CBASP.
New York: Guilford Press.
McCullough, Jr. J.P. (2001). Skills Training Manual for Diagnosing &
Treating Chronic Depression: CBASP. New York: Guilford Press.
McCullough, Jr., J.P. (2003). Patient‟s Manual for CBASP. New York:
Guilford Press.
McCullough, Jr., J.P. (2006). Treating Chronic Depression with Disciplined
Personal Involvement: CBASP. New York: Springer.
<www.cbasp.org>
The end
Any comments
or questions?