Treatment for chronic depression Cognitive behavioural analysis system of psychotherapy: McCullough

Treatment for chronic depression Cognitive behavioural analysis system of psychotherapy

Contents

Part One The psychopathology of the patient. 3

Chapter 1 A Therapists problems with a chronically depressed patient. 3

Chapter 2 Introduction to chronically depressed patients and the CBASP program.. 3

Chronically depressed patients show the following aspects: 3

CBASP. 3

Patients are responsible for their depression. 4

The nature of the depression experience. 5

Chapter 3 Understanding the psychopathology of chronically depressed patients. 5

Normal and abnormal behaviour. 5

The teleological goal for interpersonal social development. 5

Normal Development and Chronic depression. 6

Jean Piaget's structural model of normal development. 6

Two types of derailment in normal development. 7

Parallels between chronically depressed adults and normal preoperational children. 7

Differences between normal preoperational children and chronically depressed adults. 8

Normal Bifurcated cognitive emotional development. 8

Maltreatment and derailment of the maturational process among early onset chronic depressives  8

Late onset degeneration of cognitive emotional functioning. 8

Chapter 4 Course Patterns, Comorbidity and psychological characteristics. 9

Five course patterns of chronic depression. 9

Psychological characteristics of untreated chronically depressed patients. 9

Part Two CBASP methods and procedures. 9

Chapter 5 Strategies to enhance motivation for change. 10

The importance of motivation. 10

Patient misery and the negative reinforcement paradigm.. 10

Take over pitfalls. 10

Situational analysis: exacerbation and resolution of psychopathology. 11

SA must be an existential encounter. 11

Positively addressing transference issues. 12

Eliciting a significant other list. 12

Methodological issues and rationale. 13

Transference hypothesis as tacit knowledge. 13

Chapter 6 Elicitation phase of situational analysis. 13

The Coping survey questionnaire. 13

Situational description. 13

Therapist rules for administering step 1. 14

Step 2: situational interpretations. 14

Therapist rules for administering step 2. 14

Pathological patterns arising during step 2. 14

Step 3: Situational behaviour. 14

Step 4: Situational actual outcome. 15

Five common errors. 15

Step 5: Situational desired outcome. 15

Step 6: Comparing the actual outcome to the desired outcome. 16

Chapter 7 Remediation Phase of Situational analysis. 16

Step 1: Revising irrelevant and inaccurate interpretations. 16

Therapist rules for administering Step 1. 17

Step 2: Modifying inappropriate behaviour. 18

Therapist rules for administering step 2. 18

Step 3: Wrap up and summary of situational analysis learning. 18

Step 4: Generalisation and transfer of learning. 18

Administering situational analysis for anticipated future events. 19

Chapter 8 Using the therapist-Patient relationship to modify behaviour. 19

Determining the patients interpersonal stimulus value. 19

The optimal Interpersonal style for the therapist. 19

Disciplined personal involvement with patients. 20

Chapters 9-12 omitted due to clinical irrelevance to me. 20

Chapter 13 Resolving Common Patient Problems and Crises. 20

Summary. 21

Part One The psychopathology of the patient

Chapter 1 A Therapists problems with a chronically depressed patient

Working with chronically depressed patients can be demotivating as they feel helpless, you try all the techniques and nothing works, then you feel helpless and demotivated, so there’s a system Cognitive behavioural analysis system of psychotherapy that could be of use.

Chapter 2 Introduction to chronically depressed patients and the CBASP program

Chronically depressed patients show the following aspects:

·         Repeated expressions of misery and helplessness

·         A submissive defeated demeanour

·         Wariness of interpersonal interaction

·         An entrenched conviction that nothing can help their depression

·         Rigid and stable behaviour patterns that are restraints to positive and negative events

The therapist may well feel:

·         Need to fix the patient

·         Need to be dominant

·         A sense of helplessness

·         A feeling of apprehension working with someone who is so detached

The questions a therapist needs to ask\answer are

1.       How can I effectively treat someone who is demotivated

2.       What can I do to neutralise the feelings of helplessness that is interfering with therapeutic work

3.       Why do I feel helpless and inadequate working with this patient

4.       Why do I feel that nothing I do will make a difference

5.       Why do I feel that changing the patients behaviour is up to me

Dysthymia is a low level of chronic depression

CBASP

1.       Designed for chronic depression

2.       Understands depression as environment*person

a.       Faulty coping in the face of environmental stress

b.      The deleterious effect on the biological and psychological processes of inadequate coping

c.       Chronic depression results from maladaptive social problem solving and a perceptual blind spot that doesn’t see the link between what they do and the effects on others, which I guess means their deterioration in mood and cognition

d.      Social coping is derivative of

                                                               i.      Cognitive emotional construction of self

                                                             ii.      Social skills

                                                            iii.      Past history of interpersonal stress management

                                                           iv.      Ability to tolerate stress

                                                             v.      Degree of social support

3.       Aims at social problem solving and empathic responsivity in social interactions

a.       The therapist should be personally involved so as to model empathy and problem solving techniques.

4.       Negative reinforcement used as motivational strategy

5.       Uses situational analysis

a.       Target a problem, understand it situationally, look at the cognitions and emotions involved in it. Once the current consequences of behaviour are seen then a more desirable outcome can be stated and a problem solving attitude used to target what the solution might be.

6.       Arrested maturational process is seen as the etiology of chronic depression

a.       You can’t use logical reasoning with the chronically depressed, they don’t interact empathically and their behaviour isn’t changed by the reinforcement of family and friends. After the arresting of development there is a feeling of helplessness and hopelessness.

Patients are responsible for their depression

A lot  of clients don’t want to take responsibility, it’s a chemical imbalance, it’s because of what’s happened to me, it’s how I am. Psychotherapists, work to get clients to take control over their lives. If you assume total control, you have the capacity to change it.  The therapist can help this attitude by showing the patient the consequences of their actions, then it’s up to them if they want to change them. Once patients become aware of the type of life they have created and how then they can start to choose differently.

Assumption 1 Chronic depression is best understood as a person’s failure to cope with life’s stressors

Assumption 2 When a person sees their depression as an outcome of person interacting with environment then this results in behavioural change and empowerment

The nature of the depression experience

Three models:

1.       Intrapsychic: Beck

2.       Interpersonal: Klerman

3.       Biological

The general thread through all of these is a sense of helplessness resulting from a self-perception of inadequacy. The negative sense of self results in social withdrawal. Depression then is the interaction of these three systems, intrapsychic, interpersonal and biological

Depression is a sign of stress has overextended our coping capacities. The normal cycle is withdrawal, rebuilding and coping to recovery cycle.   The pathological response happens when in the withdrawal instead of a rebuilding then sadness increases, the problem worsens and a depressive cycle ensures.

Chapter 3 Understanding the psychopathology of chronically depressed patients

Normal and abnormal behaviour

Chronically depressed patients have developmental limitations.  When you talk about dysfunction, you talk about a mental structure having a certain function to operate normally. Normal is defined by both facts, and value, as what facts are selected are defined by the values of sociocultural standards.  Abnormal behaviour given it emanates from where normal behaviour comes from then is an extension of normal behaviour.  Indeed every psychopathology can be seen in watered down versions, transient version in everyone.

CBASP basis itself on Piaget’s model of human development

The teleological goal for interpersonal social development

Mature development, coming from Piaget, is to be able to communicate and place oneself in the shoes of the listener. Learning how to be more empathic is one of the goals of CBASP.

Learning to be empathic is from modelling and in relationships where empathy is valued.  When people are being empathic then it signals that a person is making themselves understood and there is an equal motivation to understand the language of the other.  From a structural development perspective then empathic encounters denotes the ability to use abstract thought or from Piaget's nomenclature formal operations thought. Chronically depressed patients appear to lack a strongly developed sense of empathic behaviour.

Perceived functionality thinking is the thinking that your behaviour has specific consequences in the world.  So you are aware that how you act has an impact on the other, and yourself, and how the other acts has an impact on how you are.

Empathic behaviour is never fully realised, we can never inhabit the others shoes. For CBASP it is the ultimate goal of social development.

Normal Development and Chronic depression

Jean Piaget's structural model of normal development

Piaget concerns himself with both the development of cognitive and emotional organisation. He believed that cognitions and affect are indissoluble, where there is one there is the other. For Piaget emotions affect cognitive development by influencing what children seek out or avoid.

The entire interpersonal cognitive and emotional universe of the child is centred on the early attachment to the mother.

Emotions according to Piaget act as an energising force driving cognitive behaviour and development. Affect is the petrol that drives the car, cognitions are the engine. So the engine directs the energy from the petrol.

Piaget noticed that affect is progressively organised over time, paralleling similar cognitive activities. When derailment occurs in development then emotional dysregulation and asynchrony occurs between cognitive and emotional processes. One possible outcome of this is early onset of depression. Early onset of depression starts before 21 which usually signals a long standing and non-remitting chronic depression.

In normal development there is a process of decentring, where the self is detached form itself and you can disengage from the present moment. This is a movement from understanding the present as static images, to be able to create rules that can transcend the present moment. Thus to get to Rome take one step, then another, would not be a possible rule for a baby. The final step in decentring is when one learns abstract thinking. Decentring happens during the first two years and enables a child to be in relation with others. This process depends on the primary care giver drawing the child out into the world, into relations with others. The decentring process is associated with the construction of self-esteem, i.e. towards the mastery or otherwise of the environment. Decentring generally finishes around the age of 6 to 7.

The normal developed child, then:

·         Sees an emotional response as one response amongst others, so an emotion will not be always how they feel

·         Sees other people as one type amongst different types  , so one person is not representative of all people

·         Sees one interpersonal interaction as one interaction amongst many possible ones and therefore avoid the conclusion that all interpersonal relationships will be like this

The chronically depressed patient however believes

·         When depressed they will always feel like this

·         One person who they have a problem with shows them that all people will be like this

·         One social interaction that doesn’t go well defines how all social interactions will go

The perception of time literally stops for the chronically depressed patient where the past defines interpersonal possibilities in the present and in the future.

Two types of derailment in normal development

Piaget’s theories suggest two types of derailment, infant development is retarded and adult heightened emotionality leads to a functional regression. The first condition relates to early onset patients, the latter to late onset patients.

Infant disturbed development can be the case from stimulus impoverishment. In adults an emotional flooding can happen, which can undermine mature control functions and affect a regress to the pre-decentred child.

Parallels between chronically depressed adults and normal preoperational children

There are striking similarities between chronically depressed adults and normal preoperational children.

1.       Both groups use global and prelogical thinking

2.       Their thought processes are not influenced by the rationality of others

3.       They are egocentric in their views of self and others

4.       Verbal communication is essentially monologue

5.       Interpersonal empathy is beyond both groups

6.       Both groups exhibit poor affective control under stress

1.       Chronically depressed patients think in a prelogical and precausal manner

a.       They move from a premise to a conclusion with no stops in between, the world is the way I see it, because I believe that. Likewise patients belief in global terms, I will always be depressed\unliked\boring.

2.       Chronic depressives are unaffected by logical reasoning and the rational views of those around them

a.       So an inability to see how behaviour affects self and others.

3.       Chronically depressed patients are egocentric in their views of themselves and others

a.       The person’s worldview is unassailable because they believe it to be true.  They cannot allow others into their phenomenological sphere. They feel they are the centre of the universe.

4.       Chronic depressives talk in monologues

a.       Chronic depressed patients talk as if they are thinking aloud. This is non-cooperative talk where the other is not let in.

5.       Chronic depressives lack empathy

a.       Empathy must not be concerned with emotional sensitivity.

6.       Chronic depressives lack emotional regulation under stress

a.       Chronic depressed patients are thrown into a state of helplessness and hopelessness when under stress

Differences between normal preoperational children and chronically depressed adults

Child is in development, although if their environment is hostile then this is stunted as they concentrate on basic survival. The challenge then for psychotherapy is not to deal purely with someone with negative thinking, but rather an adult child.

Normal Bifurcated cognitive emotional development

Some patients can think abstractly towards inanimate objects but not within social relationships. The schematic split then is between animate and inanimate objects. 

Maltreatment and derailment of the maturational process among early onset chronic depressives

Due to early bad experience, this experience is then projected forward and others are seen as those that will harm them given the opportunity.

There are four types of early maltreatment that can lead to an adult acting like a wounded child

1.       Physical abuse

2.       Sexual abuse

3.       Physical neglect

4.       Emotional maltreatment

Four familial themes among early onset chronic patients

Most chronically depressed patients were not adequately parented or socialized.  There are four common themes

1.       Early family environment did not recognise a child’s physical or emotional needs

2.       A child was in a dangerous family environment to their physical well being

3.       Physical and emotional pain led to tension, anxiety and fear was prevalent

4.       A child was thrust into the role of caregiver to an adult

The child adult then expects all people to react in the same ways as were their early experiences, in some ways they are trapped within that time, not being able to abstract themselves out of it, not being able to remove themselves from the concrete snapshot of life.

Early onset depression often occurs around the age of puberty when the demands of pubescence cannot be met by the child, and withdrawal and depression follows.

Late onset degeneration of cognitive emotional functioning

Late onset patients have a milder experience of maltreatment than do early onset.

Dysphoria=general dissatisfaction with life

Dysthymia=mild chronic depression

Dysmorhpia=a form that is hard to bear

Chapter 4 Course Patterns, Comorbidity and psychological characteristics

Five course patterns of chronic depression

Chronic depression is depression which lasts for 2 years and has no more than a two month cessation of symptoms.

The chronic disorder can be categorised in terms of 5 course patterns:

1.       Dysthymic disorder: mild to moderate depression usually beginning in adolescence

2.       Double depression: Recurrent major depressive incidents superimposed on a dysthymic disorder

3.       Recurrent major depression  lasting for 2 years without remission between episodes

4.       Chronic major depression, one major depressive episode lasts for more than 2 years

5.       Double depression\chronic major depression

When treating a major depressive incident, if dysthymia is suspected then treatment should continue to address the dysthymia as this will increase the chance of relapse to the major depressive incident.

Personality disorders are frequently seen occurring with chronic depression. This makes the work even more arduous.

Psychological characteristics of untreated chronically depressed patients

Hopelessness is things are in a poor state of repair and won’t get better, helpless I can’t change my hopeless position. They have low emotional regulation and low sociability. Chronic patients see no end to their depression, stability and that it affects all aspects of their life, globality. Chronically depressed patients rely on wishful thinking and blaming themselves as two ways to deal with stress. Patients are unable to focus on single problems but rather focus their problems in global terms. Patients are often in a submissive style and draw people into being dominant either through a pull or a push. Dominant behaviour only reinforces submissive behaviour.

Part Two CBASP methods and procedures

So the key elements of the chronically depressed are

1.       Hopeless: things are bad and won’t get any better

2.       Helpless: I’m powerless to affect my life

3.       Submissive

4.       Emotional dysregulation

5.       Poor interpersonal skills

6.       Lack of empathy

Tough client no!!

Chapter 5 Strategies to enhance motivation for change

The importance of motivation

The central motivational predicament faced by the therapist is the client says, it doesn’t matter what I do, I will always be depressed.  The chronically depressed client has usually tried everything and found that it doesn’t work and so has given up trying.

For motivation to be gained the key element is that the patient must see that behaviour has consequences and in turn consequences influence behaviour.

The preoperational fiction that a client operates in, is what they do doesn’t matter, whilst they believe this then they will be helpless. When they see the effects of their behaviour then they can become powerful.

Precausal thinking is others should behave how I want, simply because I want them to.

Causal thinking is I will ask others to behave how I want and reward them when they do.

The trap with preoperational thinking is that you tell the person what to do, i.e. you become dominant to their submissive wishful thinking approach

Patient misery and the negative reinforcement paradigm

The basis for patient change lies solidly in their misery and negative reinforcement from there.  The therapist needs to be on the lookout for behaviour that is negatively reinforced.

So I feel bad because I feel helpless, I do something that makes me feel less helpless, I get relief from feeling bad because of being helpless. So the trick with clients is to show them how their behaviour has had a consequence and that the consequence has given them relief from feeling hopeless.

Whilst positive action has both positive and negative reinforcing effects, it’s probably more efficient to focus on the negative reinforcement as this is the large sum of affective energy. Likewise the patient needs a reduction in their misery to remove themselves from their depression, so the more negative reinforcement that can be done the better.

Take over pitfalls

The temptation exists for the client to take over the clients concerns as they are unmotivated. As a result the client remains unmotivated and learns nothing.

Ways in which the therapist can take over

1.       Interpreting the clients behaviours

2.       Cajoling, preaching etc. for them to behave differently

3.       Telling the client what they should and shouldn’t do

4.       Fortune telling, telling the client that things will get better

The reason why therapist s end up acting like this is because

1.       The client is so dejected, that as a caring person the therapist wants to relieve suffering as soon as possible

2.       A lack of success may lead to feelings of frustration and goad the therapist to action

It’s almost as if the therapist says, right if you’re not going to do the work I’ll do it for you. But don’t take responsibility for the work only the client can do.

Situational analysis: exacerbation and resolution of psychopathology

Situational analysis has two phases the elicitation phase and the remedial phase. During the elicitation phase then SA acts as an interpersonal and cognitive tool. Here the patients specific contribution to a social encounter are elucidated which will reveal interpersonal, cognitive and behavioural pathology. During the remedial phase, specific pathologies are targeted to bring about more functional outcomes.

There are six prompts for SA during the elicitation phase

1.       Describe what happened in the situation

2.       Describe your interpretation of what happened

3.       Describe what you did in the situation

4.       Describe the actual outcome for you

5.       Describe the desired outcome for you

6.       Did you get what you wanted, if not why not

The remedial phase has the following prompt questions

1.       How did each interpretation contribute to your obtaining the desired outcome

2.       How did your behaviour help you achieve your desired outcome

3.       What did you learn in going through SA

4.       How does what you learned in this SA apply to other situations

Dealing with the negative affect

During the elicitation phase, the negative affect of the situation is often repeated. It is useful to point these out so patients can compare the affect with and without a solution and then see this as a relief moment. As a solution appears it is imperative to look at the negative reinforcement. So how they feel with solution and without and show how their behaviour has created this. This then links behaviour to outcome which is negatively reinforced.

SA must be an existential encounter

If the patient just talks about the situation, then they will merely be an observer. What you need is to get them to re-experience the encounter, as if it was happening for the first time. 

In the elicitation phase, describe factually what happened, then in one sentence structure state what the event meant to you.

Positively addressing transference issues

The therapist patient relationship is used in a salubrious way via the Interpersonal discrimination exercise IDE, which brings into relief the patients consequences of behaviour by making explicit the therapists reactions to segments of their interaction. The transference issues can be that the clinician will reject the client or will abuse them or the client will become dependent then abandoned. However it is this negative view the client has that can do most work, if the therapist makes it explicit. So when a client doesn’t get rejected, doesn’t get punished when they make a mistake, doesn’t withdraw when the client needs them then this needs to be highlighted as this will reduce the depression that people will always behave like this, there is negative reinforcement here if it is made explicit

Eliciting a significant other list

In the second session the patient is asked to describe the significant others and how they have influenced the direction of their lives, this involves the patient in abstract thinking. What you’re looking for is the client to form consequence phrases, they did that and the consequence on me was that.

Pitfalls in eliciting the significant other history

1.       Therapists should avoid drawing conclusions for the patients

2.       Therapists should avoid patients free-associating about significant others and not draw conclusions

Constructing the interpersonal transfer hypothesis

After getting the ways of behaving learnt from significant others, then the therapist can determine how these behaviour patterns may be transferred to therapy.

There are four transference domains to be considered

1.       Moments in which interpersonal intimacy are felt by either client or therapist

2.       Situations in which client has emotional needs

3.       Situations in which the client fails or makes a mistake

4.       Situations in which negative affect are directed at the therapist by the patient

These areas are noted as they are continually areas where the chronically depressed have shown habitual patterns due to early childhood experience.

The clue with the IDE is when you know who the significant others are to ask in a situation between client and therapist to ask how the significant other would have responded and how it would have made them feel, then ask them how it was between us. On the basis of this, then there starts to be a challenge to the idea that people will always act as the significant others have. Indeed there may be negative reinforcement as the depression that all people will act like this is reduced

Methodological issues and rationale

Transference hypothesis as tacit knowledge

Much of the awareness of the causes of preoperational behaviours are tacit, that is outside consciousness, almost preconscious in that they can be brought to consciousness.

Chapter 6 Elicitation phase of situational analysis

Having tangible means to demonstrate to a client there is order in their lives when all they see is disorder is to instil a ray of hope.

SA requires the patient who is at the pre operational level to think at a more advanced level of formal operations, or abstract thinking if you don’t want to talk Piaget

The revision of preoperational orientation is accomplished in SA by

1.       Focussing patients global thinking patterns on certain events

2.       Highlighting moments of interpersonal causality, showing how the client effects their world

3.       By confronting clients with the consequences of their submissive style

4.       By manoeuvring them into talking dialogically with the therapist as opposed to in a monologue

5.       By undermining hopelessness and showing them how they feel better when they behave adaptively

The Coping survey questionnaire

At the end of the second session then the client is given the CSQ to complete for the next session, they are also given the client CBASP handbook.

Situational description

Clients often want to talk about all problems, and don’t see how focussing on one problem will be any help. If we focus on one problem then we stand a better chance of addressing it, and the things we learn out of this focus can be applied to other situations. Verbal permissiveness does not help behavioural change. Interpersonal rigidity is the style for the chronically depressed client for whom time has stopped. Focussing on one problem at a time is not something that the chronically depressed client does, so this conceivably opens up a new vista for the client. The chronically depressed client thinks in global terms, so giving the description a time slice, a beginning and an end will be oppositional to this. What it will also do is form the basis for an analysis in terms of consequences and allow the client to apply this formula to other aspects of their lives.       The end point must be described in behavioural terms, these are the consequences that we need to relate to the behaviour. Hmm or, the endpoint must be defined in behavioural terms or objective terms so that the client can step back and see what has happened, avoid any global pronouncements  Avoid guessing the interpretation of others motives etc., just stick to what happened and your interpretation of it.

Therapist rules for administering step 1

1.       Rationale: you can manage your life more effectively if you think about one specific problem at a time rather than life in general. This helps with problem solving. Solving one problem then can give the tools to reapply to another problem

2.       Teach the client to describe one interpersonal event, that has a beginning point, a narrative and an end point

3.       Teach the client to describe the event from an observe perspective

4.       Don’t editorialise the description how you felt, how you thought the other felt or thought

5.       A situational description that lasts 3 or 4 minutes is optimal, any more chances are client isn’t on track

Step 2: situational interpretations

The patient is now asked to interpret the event, by the therapist asking, what did the event mean to you and by answering it with three or four concise sentences. Interpretations act like a rudder through the scenario and explain why you acted in the way that you did

Therapist rules for administering step 2

The interpretation explains your behaviours and responses in the event. The therapist should let the client do the work and not offer interpretations. Anything the therapist does for the client means that the client won’t be able to do it for themselves

Adverbs such as maybe, perhaps, always, again are generally conjectures and need to be grounded in specifics. The interpretation needs to be about what just happened, not what it means for the future.

Stick to three of four interpretations or you will have too much information on the table

Pathological patterns arising during step 2

Some times the amount of affect makes it difficult for the patient to focus, in this event then break down the focus on to step by step what happened.

General categories of maladaptive interpretations

1.       Global interpretations

2.       Avoidant interpretations which remove the patient from the problem in hand

3.       Self-blame interpretations

4.       Self-negations where the persons positive qualities are overlooked

5.       Perfectionist interpretations, my husband never does it right

6.       Conjecture interpretations I’ll never be close to anyone

7.       Wishing thinking avoidant I wish this had never happened to me

Step 3: Situational behaviour

In this section, which I’m struggling to understand at the moment, you need to get the client to describe what they did. So as much as there is an observer description of what happened, I said would you like an omelette and she said no. Then I guess this stage is describing how you said would you like an omelette, what your body language was, where you standing near or far, shouting or whispering, maybe you were complaining, so describe the type of behaviour that asking would you like an omelette is. What is also significant here is how you would have liked to behave, I really wanted to ask for a steak but I asked for an omelette as I was afraid. You can bring affect in here, were you crying?

The aim of this step is to fully understand how the patient’s behaviour contributed to the outcome, so it’s a detailed description of that behaviour and how the other person might receive it. Sometimes a client may react hastily, feel angry and lash out, so when they say can I have an omelette they are being angry.

So here the types of behaviour are lack of assertion, so I wanted to say something but I said nothing. Lack of emotional regulation, I lashed out.  Avoidant behaviour, I clammed up, I got drunk, I ate etc. Did you act hastily, did you withdraw, did you let emotions rule your behaviour, did you avoid the situation.

Behaviour can also be what didn’t happen. I wanted to talk to him but I didn’t.

Step 4: Situational actual outcome

Ask the patient how did the event come out for you? This pinpoints the actual outcome. The outcome needs to be described in behavioural terms.  This step also attempts to make the patient aware of their connection to others.

Five common errors

1.       The AO is not temporally anchored

2.       The AO is formulated in emotional terms

a.       The AO needs to be formulated in objective terms, that are observable

3.       The AO is ambiguous

4.       The client revises their AO in subsequent steps

a.       Choose a point in time as the outcome and stick to it, otherwise it becomes a moving target

5.       The therapist works with multiple AOS

I again struggle with this step. What is the actual outcome? So I had a phone call with my girlfriend where she said she didn’t know when she wanted to see me. I became sad and desolate and overate. So I guess the actual outcome is over eating.

Step 5: Situational desired outcome

This helps the client establish a marker by which they can assess the adequacy of their performance. Helps with goal orientated thinking. The difference between AO and DO provides some discomfort that can be eased through goal orientated activity. It sets the stage for negative reinforcement.

What the therapist should aim for is one distinct desired outcome. If there are a list then take the most important. DO’s should always be behavioural. You can use emotions but they must be cached out in behavioural terms. The therapist also needs to coach in terms of constructing achievable and realistic goals. A DO can’t really be set in terms of how the other reacts, it is out of your control.

If the DO raises distress then the DO should be revised, as there is not an emotional buy in to it. Here the therapist should question the desirability of the goal. Some DO’s are counterattack, she hurt me and I want to hurt her back, in this instance stepping back to find out how hurting her back would make you feel and behave could be useful.

When a client has a hurtful DO, then it can be useful to go back to the interpretations step to see what they were thinking about what happened.

Step 6: Comparing the actual outcome to the desired outcome

The prompt question here, is did you get what you wanted. The client needs to see what of their behaviour created the actual outcome and what they could do differently to get their desired outcome

Chapter 7 Remediation Phase of Situational analysis

In step 6 the question of why you didn’t get your DO are asked and typical patient responses in the early stages of therapy are global statements, because no-one likes me. The aim here is to shift the patient to more causal thinking. The aim is to move from the global to the specific. Step 6 is the instigator of the remedial phase.

The remediation phase asks what must the patient do differently to achieve their DO. The aim here is to learn through “fixing” a historic problem such that you can learn to behave differently.

This is likely to be difficult for the client, as they will be talking about a distressing event with a therapist who they don’t know and at early stages may not trust.  A client needs to feel emotion during this period, if they are emotionally detached or do not recognise their emotions then the prognosis is bad, and negative reinforcement isn’t going to work.

Step 1: Revising irrelevant and inaccurate interpretations

The AO and DO need to be operationalized behaviourally. This makes for a clear behavioural gap, if they weren’t both operationalized in this way, you wouldn’t be able to compare them.

What you do here is to go through each interpretation and ask how does it allow you to get what you want? The more accurate and relevant the interpretation the easier it is to generate an action plan. Relevant interpretations anchor patients in a time slice and concentrate their efforts on the problem at hand. Accurate interpretations enable one to assess what is happening in the situation.

So the step here is to move from irrelevant and inaccuration interpretations to relevant and accurate. So what is happening here now and what do I think of it (I think!).

So as an interpretation is looked at, e.g. I failed again, was it relevant, was it grounded in the situation. The accuracy is about whether it correctly reflects what is happening.

As the interpretations are altered so the DO may well be altered, for instance a DO I must talk to my boss now, and then he says he’s busy would alter the DO to I will schedule a time when I can talk to him.

You need to be able to produce realistic and attainable goals, this is why behaviourally couched goals are chosen as they are just that. Often people have DO that are not realistic and attainable and this is why they are continually frustrated.

If the DO isn’t attainable then get the patient to see that the environment won’t deliver and get them to come up with something they do want.

Chronically depressed clients will need a lot of practice at improving their interpretations and modifying their DO’s accordingly.

If you have a DO that you hold to rigidly then fail as the environment makes it unattainable, then you think that didn’t happen as I’m just inept, then castigate yourself, then this is self-centred global thinking that doesn’t help you achieve your goals.

Success is when AO=DO and should be celebrated, some clients will try to not celebrate, see it as luck, or the environment. SA prevents the client from escaping from the reasons why they fail and prevents them from not celebrating their successes.

As skinner said consequences influence behaviour only if we recognise the relation between behaviour and consequences.

Therapist rules for administering Step 1

1.       Review each interpretation in the sequence that they came up in, as interpretations build on each other, so only really make sense sequentially

2.       Review each interpretation for its relevance and accuracy and see how it either impeded or helped to get their goal

3.       You should always focus cognitions of the specific problem in hand and not generalise to other situations

4.       The therapist should never discard or revise an accurate and relevant interpretation even if it doesn’t contribute directly to the DO

a.       Good environmental reads ground a person in the realities of the situation

5.       When depression doesn’t shift then the SAs need to be moved into the room..how?

a.       Look at any interpersonal obstacles so take the roadblocks they have had outside the room and ask if to do an SA on when these have happened inside the room

With disputational tactics and thinking errors, very few chronically depressed patients would disagree with their therapist, they would agree verbally but not change their behaviour.

Sometimes role playing with clients can help them hear their verbal style and see the impact that it has on others.

When interpretations get changed into action, this is called an action read, so if a client thinks, I’ve got to act in a different way to achieve my DO then you have an action read and really this is one of the goals of SA.

The standard set up with Dos is that behaviour+environment doesn’t equal DO. So the variables to change are the behaviours, or the DO.

Good accurate and relevant interpretations are useful even if they don’t track the DO as they may well in time lead to it, only discard the DO when you realise it is ultimately unattainable. Accurate monitoring whilst keeping your eye on the bulls eye is the way to go.

Sometimes clients will bring in successful SA’s whilst ignoring the important but difficult SA’s.

As the client comes close to finishing therapy then you need to make more input and get them to correct their interpretations and DO’s.

Step 2: Modifying inappropriate behaviour

When step 2 is completed then the patient has identified their inappropriate behaved and remedied what they would want, so they can see how they should act. Often clients say I could never do that, now a therapist needs to take this seriously but also not feel that they need to modify it immediately. The therapist should use the DO, if you really want the DO then you know what behaviour you need to do. Clients can be very frightened at this point, if they have been depressed for many years and now the possibility to change this becomes apparent then there can be a lot of fear through changing their habits.

So to the client then knowing what they need to do is stage one, then when they are ready they can approach it, through brain storming solutions in the office, through role playing them, through practising them is non-threatening situations.

Therapist rules for administering step 2

1.       Step 2 can be introduced by saying now that you have interpreted the situation differently how would you behave differently to get the DO

2.       Some behaviours need to be modified, some need to be added

Step 3: Wrap up and summary of situational analysis learning

This step is a summarising of what the problem was and what the solution is, so a combination of new ways of interpreting and new ways of behaving.  It is essential that the client summarises this rather than the therapist so they learn.

Step 4: Generalisation and transfer of learning

The first step in generalisation is to apply learning to recent past events.

Therapist rules for administering Step 4

1.       Be specific, so ask if there are other situations this applies to and if a client says oh yeah my job, then operationalize this, behaviourally ground this in specificity.

Administering situational analysis for anticipated future events

Format for using SA is a four step process

1.       Patient pinpoints DO in behavioural terms

2.       Pinpoints the most likely DO

3.       Patient delineates the behaviour likely to achieve the DO

4.       Patients identifies what interpretations will be required to produce the DO

Chapter 8 Using the therapist-Patient relationship to modify behaviour

So using the therapist\patient relationship to modify the client’s behaviours requires the therapist to be congruent, and to be able to give helpful feedback even if it isn’t positive. So this needs to be done without breaking the therapeutic alliance

So how this works is

1.       Generate the significant other list

a.       List of people in your life and how they affected you

b.      Generate hypothesis of situations when  the transference might work

2.       In the room in a certain type of situation then ask how the significant other would have reacted and how the therapist acts and what this means to the client

a.       Being intimate

b.      Client making a mistake

Determining the patients interpersonal stimulus value

Do an IMI questionnaire and work out how you’re responding to your client which can tell you something of their interpersonal style. The IMI helps the therapist to avoid acting in unhelpful knee jerk response styles, so for instance maybe they might become dominant with passivity, this would be unhelpful to the client, so knowing this ahead of time would help prevent this happening. The imi states that dominant has a pull on submission and vice version, friendly pulls friendly, hostile pulls hostile. Friendly dominant, is I’m clever and will dazzle you with my talent which pairs with friendly submissive you’re wonderful, I trust you completely.

The optimal Interpersonal style for the therapist

So friendly is best, dominant is understandable to start off with but must be reduced to let the client do the work, if the therapist is dominant then this may evoke a submissive reaction from the client, which is absolutely what the client needs to get away from.

Frustration and anger are often therapist responses with the chronically depressed. If these are acted out then this will increase the client’s sense of isolation.

Anger principles

Principle 1. Anger is usually a sign that the patient is perceptually disengaged from the therapist or is not aware of the interpersonal consequences of their behaviour

Principle 2 try to avoid withdrawing from or attacking the patient

So one way to deal with this, gulp, is to ask the patient why do you want to treat me this way, so the actual question would be why do you want to make me feel frustrated and upset with you.

Sometimes the problems happen outside the room, so a patient with a known unsuitable partner, keeps on having problems with them and keeps on going back to them. A way to deal with this is consequentiation, so what happens when you go out with x, you get hurt, why doesn’t he treat you differently, why do you suppose he does it, going about it in this way, will show that the client is involved in wishful thinking

Disciplined personal involvement with patients

Clinicians need to have personal involvement with clients

1.       If a client needs to learn empathy this can only happen through personal disclosure of their feelings with the client

2.       The therapists reactions should be used to show the difference with significant others who have maltreated the client

3.       When clients behave in a hostile, destructive manner then the therapist can tell them of the hurtful effect on them, so the client can be aware of the effect they are having on others

Chronically depressed patients may be unused to positive feedback, care, support and the like. Therefore when this happens from the therapist this must be made explicit, how was it for you when I showed care to you.

Chapters 9-12 omitted due to clinical irrelevance to me

Am I bad?

Chapter 13 Resolving Common Patient Problems and Crises

The underlying principle of CBASP is the person * environment behavioural model.  When clients feel helpless it is often as they don’t realise the consequences of their behaviour.

A suicidal patient wields enormous power and can mobilize friends and family and mental health community.  Whilst this is only recommended to experienced therapists with a very strong alliance with a patient who hasn’t

1.       A plan

2.       Severe anxiety\panic attacks

3.       Alcohol dependence

4.       Anhedonia

The therapist can then ask what the clients suicide will mean to them and express their personal feelings, sadness and anger.  If this doesn’t mitigate the risk then hospitalisations the next step. What this does though is shows the consequences of behaviour.

Clients who continually bring crisis avoid looking at underlying issues, and you spend too much time putting out the forest fires. In this instance the therapist must concentrate on doing SA’s on what is happening between them, this will intensify the relationship.  Bringing the focus into the moment, can look at interpersonal issues that can be creating problems outside the room.

When a client continues to have similar problems, and SA doesn’t make any difference there is a strong chance that there is.

When a therapist’s congruence is important is where the client has a break down with their environment. So hostile obsessive people exist within a world of their obsession. Creating a problem for the patient is asking why they want to be hostile to the therapist. The successful outcome of this is where the client cares about the therapist and empathy is restored.

Cognitions and behaviours are important in so far as they produce consequences. If they become important in themselves there is the danger of this turning into an intellectual exercise. The spirit of SA is consequating behaviour, so don’t focus so much on doing every step right.

Sometimes people have consequences that don’t bear relation to situations, so a global I’m worthless for instance.

In this instance you can either create a new situation, you feel guilty and worthless about doing x, when you tell me and I don’t feel guilty, then why is that.

The other approach is to get the client to answer what the therapist thinks of their self damning comments that are without a situation, the therapist then expresses their care, and the awkwardness of hearing the comments. This then provides a situation in which the therapist reaction can be investigated. It also shows the consequences on another of hearing these things, then this can be parallel back to what it’s like for the client, i.e. consequences.

Summary

So to CBASP. This is a treatment aimed at the chronically depressed. These are a difficult group to work with as they:

1.       Have very low motivation

2.       Don’t see the link between their behaviours and their situation

3.       Lack empathy

4.       Think in global terms of helplessness, I can’t cope and hopelessness, things will never get better

CBASP then using negative reinforcement seeks to help a client to see the relation between their behaviours and their situation. This empowers the client as they firstly become responsible for their life and in doing so have the power to change.

The key within CBASP is to get the client to do the work, they need to relate behaviours and consequences, if the therapist does the work the client learns nothing.

CBASP focuses on social problem solving, i.e. interpersonal problems. I guess the reason for this is that any task of any significance involves people.  The aim of interpersonal problems being key can also be understood through how CBASP understand the etiology of chronic depression. The standard onset for the chronically depressed is prior to 21. There is also a strong connection between the profile of a preoperational  child.

1.       Thinking in prelogical and precausal ways. Their own causality doesn’t cause their world, nor does logical intervention change it

2.       No empathy

3.       Lack of emotional regulation under stress

There are then two roads to chronic depression, the early onset, which is pre 21 where there is evidence of a history of maltreatment:

1.       Emotional abuse

2.       Physical abuse

3.       Sexual abuse

With late onset, typically in midlife, then there was a lesser degree of maltreatment, merely opening up a propensity to chronic depression.

Thus with interpersonal maltreatment starting chronic depression, targeting interpersonal  problems will get to the source of the problem, and will be effective given that the tasks that bring the most pleasure and mastery are the more involved ones that involve other people, cooking for self or cooking for friend, thinking or talking, doing your garden, or working as a gardener….

There two main techniques in CBASP and they are situational analysis and the Interpersonal discrimination exercise.

Situational analysis, SA works by allowing the client to see how their interpretations and behaviours contribute to their outcomes. It then seeks to highlight the difference between the actual outcome and the desired outcome. Then the interpretations and behaviours are modified to get towards the desired outcome, although sometimes the desired outcome is modified in the realisation that it is unattainable. As soon as there is realisation that the actual outcome is produced by behaviour and that the client can get closer to the desired outcome, if not achieve it, then there is negative reinforcement as the depressive feelings that accompany helpless reduce and the feelings of pleasure and mastery increase. This must be highlighted so the good feelings are related to how the client has behaved, that is they have taken control and changed the situation.

In terms of session structure, the first session can be about elucidating the client’s problem list, and psycho-educating about CBASP. The second session needs to elucidate the significant other list. To do this then you need to ask the client to identify significant others that have had the most influence on the direction your life has taken, these influences can be good or bad.

After getting this list, then what you need to do is to ask the client how these people affected the course of your life, what you aim for is antecedent causal phrase, e.g. my mother never liked me, and how this affected the client, I never had any confidence in myself. So question like how did your mother influence you can be useful, what effect on your behaviour has your mother had?

On the basis of the significant other list then a set of transference hypothesis should be formed, where if the patient fails, this could produce a reaction derived from the significant other, as the therapist acts differently in this situation, then this mismatch is brought to the client’s attention between what they expected to happen and what actually did. In this they can see that they don’t always get punished for failure.

Situational Analysis

There are two parts of this, the analysis and the elucidation.

The client is asked to complete a coping survey questionnaire for an interpersonal situation, in the first instance where things didn’t work out the way they would have liked. For all of this it should be anchored in time both in terms of what happened and what the outcome was.

1.       Describe as if you are an observer what happened

2.       Give three interpretations of the event, and put them on a time line

a.       Avoid conjectures

b.      Stay in here and now

3.       Describe what you did during the situation, i.e. how you said what you said, how you moved etc., did you give up, try harder, how would you described how you behaved in the situation

4.       Describe how the event came out for you

5.       Describe how you wanted the event to come out for you

6.       Describe if you got your desired outcome

Then you move onto the elucidation phase

1.       Revise irrelevant or inaccurate interpretations

a.       Did you interpretations help you get what you wanted?

b.      Are they about the situation in hand

c.       Are they accurate about the situation in hand?

2.       Modifying inappropriate behaviours

a.       How did how you behaved contribute to achieving your desired outcome

b.      How did you need to act to achieve your desired outcome

c.       Patient learns to enact the appropriate skills

3.       Wrap and Summary

a.       Get client to summarise how they were behaving and how they need to behave

4.       Generalisation and skills transfer

a.       Find out what was learnt in the SA and then what other situations this could be applied to

During the work of moving from elucidation to remediation and skills application\training then the therapist should be on the lookout for any transference issues that highlight the hotspots from the significant other list and show the difference between how they act and how their significant other would have acted.

Again any opportunity which shows the client is feeling better the negative reinforcement should be highlighted as a consequence of their behaviour.