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cognitive behavioural
analysis system
of psychotherapy
personal background
work through a small charity whose aims are:
 to help people with psychological difficulties –
typically adults with depression and/or anxiety
when effective help is not readily available elsewhere
 to try to provide & encourage a whole person
approach using what’s best in conventional,
complementary, & self-help methods of health care
for more details & a downloadable copy of this talk go to the ‘good
knowledge’ section of www.goodmedicine.org.uk click on ‘lectures
and leaflets’ and look under ‘cbt, depression & ...’ in ‘past lectures’
why am I giving this talk?
 excited by how relevant
CBASP seems to be for
many patients that we see
 not an expert, simply an
interested fellow traveller
 sharing enthusiasms is
one of the best forms
of self-education!
key points of this talk
 why take CBASP seriously?
 what does CBASP involve?
 situational analysis (SA)
 interpersonal discrimination
exercise (IDE)
 psychotherapy depression
treatment developments
major depression often persists
percentage recovered
90
76
80
63
70
60
50
82
50
Spijker J. et al.
40
Duration of major
depressive episodes
in the general
population.
30
20
Br J Psychiatry
2002;181:208-213
10
0
3
6
12
24
time from start of depressive episode
dysthymic disorder is very common
lifetime prevalence in 7,667 young US adults (17-39)
representative sample interviewed 1988-1994
6.2%
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.
current prevalence in 3,056 elderly Dutch adults
(55-85); unfavourable prognosis commented on
4.6%
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.
12 month prevalence in 4,327 primary care
Canadian adults; 90% had comorbid disorders
5.1%
Steiner, M., B. Bell, et al. (1999). Prevalence of dysthymic
disorder in primary care. J Affect Disord 54(3): 303-8.
cbasp for chronic depression
 multisite trial involving 681 patients at 12 US academic centres
 aged 18-75, current major depressive disorder (MDD) with a
Hamilton Scale (HRSD-24) score > 19 and duration > 2 years
 either chronic MDD, or MDD superimposed on dysthymic disorder,
or recurrent MDD with incomplete remission between episodes
 randomized to cognitive behavioral analysis system of psychotherapy (CBASP) or the antidepressant nefazodone or both
 16-20 sessions over 12 weeks – a satisfactory response was
defined as at least a 50% reduction in Hamilton Scale score
 662 patients attended at least one session and 519 completed
treatment; 22% drop out rates similar across the three groups
Keller, M. B., McCullough, J.P. et al. A comparison of nefazodone, the cog-
nitive behavioral-analysis system of psychotherapy, & their combination for
the treatment of chronic depression. N Engl J Med 2000; 342(20): 1462-70
% response
response of all & of completers
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.
cbasp
combination
nefazodone
100
85
73
80
60
48
48
52
55
40
20
0
all
completers
‘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 completers
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.
cbasp
% remission
60
nefazodone
48
50
40
combination
33
42
29
30
24
22
20
10
0
all
completers
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 published
 Arnow, B. A., R. Manber, et al. (2003). "Therapeutic reactance as a predictor of outcome in the
treatment of chronic depression." J Consult Clin Psychol 71(6): 1025-35.
 Gelenberg, A. J., M. H. Trivedi, et al. (2003). "Randomized, placebo-controlled trial of nefazodone
maintenance treatment in preventing recurrence in chronic depression." Biol Psychiatry 54(8): 806-17.
 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." Biol
Psychiatry 51(2): 123-33.
 Klein, D. N., N. J. Santiago, et al. (2004). "Cognitive-behavioral analysis system of psychotherapy
as a maintenance treatment for chronic depression." J Consult Clin Psychol 72(4): 681-8.
 Klein, D. N., J. E. Schwartz, et al. (2003). "Therapeutic alliance in depression treatment: controlling
for prior change and patient characteristics." J Consult Clin Psychol 71(6): 997-1006.
 Manber, R., B. Arnow, et al. (2003). "Patient's therapeutic skill acquisition and response to psychotherapy,
alone or in combination with medication." Psychol Med 33(4): 693-702.
 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." Sleep 26(2): 130-6.
 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."
Proc
Natl Acad Sci U S A 100(24): 14293-6.
 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, and their
combination." J Clin Psychiatry 63(5): 434-41.
 Schatzberg, A. F., A. J. Rush, et al. (2005). "Chronic depression: medication (nefazodone) or
psychotherapy (CBASP) is effective when the other is not." Arch Gen Psychiatry 62(5): 513-20.
 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 depression."
J
Clin Psychiatry 63(6): 493-500.
 Zajecka, J., D. L. Dunner, et al. (2002). "Sexual function & satisfaction in the treatment of chronic major
depression with nefazodone, psychotherapy, and their combination." J Clin Psychiatry 63(8): 709-16.
highlights include ...
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.
Klein, D. N., J. E. Schwartz, et al. (2003). "Therapeutic alliance in depression treatment: controlling for prior change and patient characteristics." J Consult Clin Psychol 71(6): 997-1006.
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.
Schatzberg, A., A. Rush, et al. (2005). "Chronic depression: medication (nefazodone) or
psychotherapy (CBASP) is effective when the other is not." Arch Gen Psychiatry 62: 513-20.
& more highlights ...
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 marginally superior to psychotherapy alone among the child abuse cohort.
Nemeroff, C. B., C. M. Heim, et al. (2003). "Differential responses to psycho-therapy
versus pharmacotherapy in patients with chronic forms of major depression and
childhood trauma." Proc Natl Acad Sci U S A 100(24): 14293-6.
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 assessment only condition experienced a recurrence. The 2 conditions also
differed significantly on change in depressive symptoms over time.
Klein, D. N., N. J. Santiago, et al. (2004). "Cognitive-behavioral analysis system of psychotherapy as a maintenance treatment for chronic depression." J Consult Clin Psychol 72: 681-8.
cbasp & medication current winner
 based on best current research the
combination of CBASP and an antidepressant is the evidence-based
treatment for persistent depression
 NIMH began a further large multicentre trial in 2002 to explore the
value of adding CBASP – or a
control psychotherapy – when
persistent depression sufferers failed to
respond adequately to an antidepressant
due to report in march ‘06
the largest ever randomized psychotherapymedication depression treatment trial – a 9 site, 4
(+ 2) year study – is due to report results in 2006
910 chronically depressed outpatients were
entered 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 own
2.) medication plus Brief Supportive Psychotherapy
3.) medication plus CBASP
key points of this talk
 why take CBASP seriously?
 what does CBASP involve?
 situational analysis (SA)
 interpersonal discrimination
exercise (IDE)
 psychotherapy depression
treatment developments
some characteristics of cbasp
 cbasp aims to tackle the sense of powerlessness
and tendency to overgeneralize that are postulated
to be of crucial importance in chronic depression
 the core technique is teaching ‘situational analysis’
to help sufferers tackle interpersonal problems more
effectively & improve their sense of personal control
 the therapeutic relationship itself is also used actively
to modify sufferers preconceptions
 see handouts: ‘coping survey questionnaire’ used in
‘situational analysis’ and ‘significant others’ list & grid
used in the ‘interpersonal discrimination exercise’
key points of this talk
 why take CBASP seriously?
 what does CBASP involve?
 situational analysis (SA)
 interpersonal discrimination
exercise (IDE)
 psychotherapy depression
treatment developments
SA: situational analysis
 it’s possible to conceptualise what’s happening in
situational analysis in a number of overlapping ways
 at its simplest, one can see SA as a methodical way
of teaching better interpersonal problem solving skills
 we know that depression sufferers tend to overgeneralise & feel helpless/hopeless. SA can also be
seen as an effective way of combating these vulnerabilities – and there is research showing increases in
internalized locus of control with CBASP treatment
 James McCullough himself talks, on his website, about
helping chronic depression sufferers ‘mature’ in their
appreciation of the way they affect other’s responses
and resultant interpersonal outcomes
SA: coping survey questionnaire
 the ‘coping survey questionnaire’ is used repeatedly
over the course of CBASP treatment
 the explicit treatment goal is not so much to help
patients solve particular interpersonal problems as to
teach them to approach all such problems in a new way
 interestingly this emphasis on the crucial importance
of changing attitude (more internalized control/choice)
is backed up by other research on teaching more
general problem solving skills to depression sufferers
 there are also fascinating overlaps between this
approach and Behavioural Activation (BA), Acceptance
& Commitment Therapy (ACT), Task Concentration
Training & Mindfulness Based Cognitive Therapy (MBCT)
SA: using the questionnaire
 the patient completes one or possibly two questionnaires
each week & brings them to the weekly therapy session
 a considerable amount of therapeutic time is spent going
through the questionnaires with the patient
 the overall goal is spelled out clearly – ‘that patients
‘must learn to do each of the SA steps by themselves
and without assistance from the clinician’
 McCullough repeatedly underlines the importance of
‘getting the patient to do the work’; he claims that a
dominant, take-charge style is ‘therapeutically lethal’
for these helpless/hopeless depression sufferers
 let’s try it ... with a personal or patient’s example
key points of this talk
 why take CBASP seriously?
 what does CBASP involve?
 situational analysis (SA)
 interpersonal discrimination
exercise (IDE)
 psychotherapy depression
treatment developments
IDE: interpersonal discrimination
 it is assumed that experiences in important early
relationships will contribute to difficulties in current
and future important/close relationships
 it is also predicted that many of these difficulties are
likely to emerge in the therapeutic relationship
 rather than seeing such difficulties as a therapeutic
problem, the interpersonal discrimination exercise (IDE)
aims to turn them into ‘behavioural experiments’
 so the therapeutic relationship is used actively to help
sufferers challenge & update dysfunctional early beliefs
IDE: the significant others list
 early in treatment – usually at the
2nd session – the sufferer makes a list
of up to seven people who have had
most influence on them and their life
 this influence might be positive or
negative, but it seems a major factor
in the direction their life has taken,
the kind of person they are, & how
they feel, think, behave & relate
 the therapist is urged to interrupt
‘story telling’ & help the sufferer make
the cause-effect links for themselves
IDE: the significant others grid
 one (or possibly two) ‘transference
hypotheses’ are then constructed to
highlight particularly relevant and
destructive interpersonal themes
 these ‘hypotheses’ are focused on one
(or more) of four pre-selected domains:
intimacy, failure, need, & confrontation
 these four interpersonal domains are
targeted as they are considered to
reflect common interpersonal experiences encountered in psychotherapy
IDE: the significant others grid
the four interpersonal domains targeted in the IDE:
1. moments of intimacy when the patient opens up
emotionally to the therapist
2. when the patient makes a mistake or fails in some
observable way
3. times when the patient expresses felt emotional
needs to the therapist
4. when the patient expresses some negative affect
toward the therapist either verbally or nonverbally
(e.g. frustration, anger, shame, guilt, sexual affect
if it carries a negative connotation, etc.).
using the transference hypothesis
 the IDE is used proactively whenever the
patient-therapist encounter moves into the
targeted “hot spot” transference area
 the patient is encouraged to compare &
contrast the therapist’s behaviours in the
targeted interpersonal domain with those
of maltreating significant others.
 once the discrimination is made explicit,
patients are then taught how to function
in the new interpersonal reality existing
between himself/herself and the clinician.
key points of this talk
 why take CBASP seriously?
 what does CBASP involve?
 situational analysis (SA)
 interpersonal discrimination
exercise (IDE)
 psychotherapy depression
treatment developments
cbt treatment developments &
improving treatment of depression
 Cognitive Behaviour Analysis System of
Psychotherapy (CBASP)
 Contextual Behavioural Activation (BA)
 Mindfulness Based Cognitive Therapy (MBCT)
 Other form of Attention Training (Bogels, Wells)
 Acceptance and Commitment Therapy (ACT)
 NICE & PTSD, and the commonness of
traumatic imagery across depression & anxiety
james mcullough cbasp resources
 McCullough, J.P. Treatment for chronic depression.
New York: Guilford Press, 2000
 McCullough, J.P. Skills training manual for
diagnosing & treating chronic depression.
New
York: Guilford, 2001
 McCullough, J.P. Patient’s manual for CBASP New
York: Guilford Press, 2003
 ... and McCullough, J.P. Treating chronic depression
with disciplined personal involvement: CBASP
New York: Springer Press, due out July, 2006)
 Website with course & other details: www.cbasp.org
to download a copy of this talk
for more details and a downloadable 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”