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,
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
Situational Analysis (SA)
A group of “in-the-room therapy skills” which address the interpersonal challenge of working with people with chronic depression
Interpersonal Discrimination Exercise (IDE) Contingent Personal Responsivity (CPR)
CBASP overview (iii)
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….
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…..?
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
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…..
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
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)
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
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
Take a significant other history Construct transference hypothesis
Reflect on Impact Message Inventory
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
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)
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
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)
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
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
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?
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.
The end
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