James McCullough on His Cognitive Behavioral Analysis System for Chronically Depressed Patients

By Lynn Mollick

On Sunday, March 19 psychologist James P McCullough presented NJ-ACT’s 22^nd Master Lecture. His topic was the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) for Persistent Depressive Disorder.

According to Dr. McCullough, patients with chronic depression do not respond to Cognitive Therapy because their thinking is “pre-operational.” They are unaffected by logical argument because they do not think logically or causally. “Don’t think that these patients are like you,” warned Dr. McCullough. “They are not.”

Characteristics of chronically depressed patients:

1. Fear and avoidance of interpersonal closeness. CBASP assumes that this characteristic of chronically depressed patients was learned through past and present psychological, physical and/or sexual abuse from significant others.
2. Pervasive egocentricity and an inability to experience empathy.
3. Preoperational thinking. Thinking and speaking globally instead of specifically, and vaguely instead of clearly.
4. The belief that their behavior does not influence how others treat them.
5. Inability to accurately perceive new experiences and learn from them — perceiving all interpersonal experiences as similar to previous maltreatment.

CBASP Goal #1 — Making patients feel safe

The CBASP therapist wants chronically depressed patients to learn that the therapist does not treat them in the same abusive or hurtful ways as past significant others. To achieve this goal:

1. Identify the influence of significant others on the patient. After the initial session, ask patients to develop a list of no more than 5 significant others who played an important role in making patients the person they are. Discuss the list in next session.
2. Identify the patient’s most counterproductive interpersonal characteristics, for example:
   Submissiveness – chronically depressed patients are usually   submissive in order to avoid abuse and emotional hurt.
   Avoiding closeness – not disclosing intimate thoughts and feelings.
   Expressing direct or indirect interpersonal hostility
   Rigidity, perfectionism, sensitivity to criticism
   
3. Identify patients’ core fears. Construct a one-sentence, “if/then” statement that summarizes the patient’s most important core fear, the patient’s problematic interpersonal behaviors, and the consequences the patient expects from them. For example:“If I ask people/my therapist to do anything to meet my needs, the other person/my therapist will not like me, will yell at me, or will punish me.”
   “If I reveal this past experience, the other person will ridicule me or think I’m crazy.”
   “If I make a mistake, I will be punished.”
   “If I tell my therapist I am angry, he/she will reject me.”

Transitional Goal — Teach patients to discriminate the therapist’s behavior from the hurtful behavior of significant others

1. Therapists’ honest and open engagement with chronically depressed patients shows patients that the therapist is treating the patient differently than hurtful or abusive significant others.Learning to discriminate the therapist’s behavior from significant others’ behavior takes time. Once this is accomplished, the patient feels safe, the first goal of CBASP has been achieved, and work on CBASP’s second goal has already begun.
2. Disciplined personal involvement — CBASP therapists step outside the traditional therapist’s neutral stance. CBASP therapists use patient-therapist interactions to teach patients, in a nurturing manner, accurate perceptions of the patient’s own and others’ emotions and behavior. This enables patients to learn how their behavior influences the feelings and behavior of others toward the patient.

CBASP Goal #2 – Situational Analysis – Teaching patients to perceive others accurately and develop interpersonal skills

Begin by analyzing the patient’s interactions with the therapist. Then move on to analyzing the patient’s interactions with others. The steps of Situational Analysis are:

1. The patient chooses a specific interaction from the past week.
2. The patient describes the interaction to the therapist.
   • The incident should have a distinct beginning and a distinct end.
   • The patient should tell the story in chronological order.
   • The story should not include speculations about what the other individual was thinking or feeling, nor should it include digressions into other matters.
3. The therapist asks questions and clarifies points to help the patient relate the incident clearly. The therapist may ask the patient to write down the sequential steps of the interaction or print them on a white board or flip chart.
   Note that Situational Analysis forces patients to think causally and specifically instead of globally. In other words, Situational Analysis helps patients think in mature instead of pre-operational ways. This is a difficult task for these patients, and it requires a great deal of discipline and perseverance from therapists. Its eventual result is a patient who accurately perceives interpersonal interactions.
4. The therapist should ask the patient if the outcome achieved was the outcome the patient desired. The therapist should also ask: “What was the consequence of your doing X?” “How did thinking the way you did lead to the outcome?”
5. If the outcome achieved was not desired, the therapist should ask the patient “What could you have thought or done differently to achieve the outcome you desired?”. The therapist presents this part of the exercise as “a suggestion to help you be prepared the next time this type of situation arises.”
   Note that the patient, not the therapist, generates the possible change. CBASP therapists must guard against being dominant with these very passive patients. CBASP therapists must also maintain a friendly demeanor even though these patients are often hostile or passively aggressive.

For further study

McCullough et al. (2015). CBASP as a Distinctive Treatment for Persistent Depressive Disorder. London and New York: Routledge.