cbasp

1. cbasp cognitive behavioural analysis system of psychotherapy

2. 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’

3. 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!

4. key points of this talk • why take CBASP seriously? • what does CBASP involve? • situational analysis (SA) • interpersonal discrimination exercise (IDE) • psychotherapy depression treatment developments

5. major depression often persists percentage recovered Spijker J. et al. Duration of major depressive episodes in the general population. Br J Psychiatry 2002;181:208-213 time from start of depressive episode

6. dysthymic disorder is very common 6.2% lifetime prevalence in 7,667 young US adults (17-39) representative sample interviewed 1988-1994 Jonas, B. S., D. Brody, et al. (2003). Prevalence of mood disorders in a national sample of young American adults.Soc Psychiatry Psychiatr Epidemiol38(11): 618-24. 4.6% current prevalence in 3,056 elderly Dutch adults (55-85); unfavourable prognosis commented on Beekman, A. T., D. J. Deeg, et al. (2004). Dysthymia in later life: a study in the community.J Affect Disord81(3): 191-9. 5.1% 12 month prevalence in 4,327 primary care Canadian adults; 90% had comorbid disorders Steiner, M., B. Bell, et al. (1999). Prevalence of dysthymic disorder in primary care.J Affect Disord54(3): 303-8.

7. 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 psycho-therapy (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

8. 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. % response ‘all’ represents the 662 patients who attended at least one treatment session; ‘completers’ represents the 519 patients who completed the full 12 week protocol.

9. 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. % remission 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.

10. 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 Psychol71(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 Psychiatry54(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 Psychiatry51(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 Psychol72(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 Psychol71(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 Med33(4): 693-702. • Manber, R., A. J. Rush, et al. (2003). "The effects of psychotherapy, nefazodone, and their combin- ation on subjective assessment of disturbed sleep in chronic depression." Sleep26(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 A100(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 Psychiatry63(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 Psychiatry62(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 Psychiatry63(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 Psychiatry63(8): 709-16.

11. 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: con-trolling for prior change and patient characteristics." J Consult Clin Psychol71(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 Psychiatry62: 513-20.

12. & 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 margin-ally 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 A100(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 assess-ment 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 psycho-therapy as a maintenance treatment for chronic depression." J Consult Clin Psychol72: 681-8.

13. cbasp & medication current winner • based on best current research the combination of CBASP and an anti-depressant is the evidence-based treatment for persistent depression • NIMH began a further large multi- centre 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

14. due to report in march ‘06 the 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 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

15. key points of this talk • why take CBASP seriously? • what does CBASP involve? • situational analysis (SA) • interpersonal discrimination exercise (IDE) • psychotherapy depression treatment developments

16. 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’

17. key points of this talk • why take CBASP seriously? • what does CBASP involve? • situational analysis (SA) • interpersonal discrimination exercise (IDE) • psychotherapy depression treatment developments

18. 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 over-generalise & feel helpless/hopeless. SA can also be seen as an effective way of combating these vulner-abilities – 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

19. 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)

20. 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

21. key points of this talk • why take CBASP seriously? • what does CBASP involve? • situational analysis (SA) • interpersonal discrimination exercise (IDE) • psychotherapy depression treatment developments

22. 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

23. 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

24. 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 experi-ences encountered in psychotherapy

25. IDE:the significant others grid the four interpersonal domains targeted in the IDE: • moments of intimacy when the patient opens up emotionally to the therapist • when the patient makes a mistake or fails in some observable way • times when the patient expresses felt emotional needs to the therapist • 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.).

26. 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.

27. key points of this talk • why take CBASP seriously? • what does CBASP involve? • situational analysis (SA) • interpersonal discrimination exercise (IDE) • psychotherapy depression treatment developments

28. 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

29. 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

30. to download a copy of this 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”