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 whats 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 2002181208-213
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
Epidemiol 38(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 Disord 81(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
Disord 54(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 gt 19
  and duration gt 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
didnt 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 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
  combin- ation 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.

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 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.
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 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
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 Psychol 72
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-medicati
on 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

• its possible to conceptualise whats 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 others 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
• lets try it ... with a personal or patients
  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

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.).

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 therapists 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. Patients 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