Treatment for chronic depression Cognitive behavioural analysis system of psychotherapy
Contents
Part
One The psychopathology of the patient
Chapter
1 A Therapists problems with a chronically depressed patient
Chapter
2 Introduction to chronically depressed patients and the CBASP program
Chronically
depressed patients show the following aspects:
CBASP
Patients
are responsible for their depression
The
nature of the depression experience
Chapter
3 Understanding the psychopathology of chronically depressed patients
Normal
and abnormal behaviour
The
teleological goal for interpersonal social development
Normal
Development and Chronic depression
Jean
Piaget's structural model of normal development
Two
types of derailment in normal development
Parallels
between chronically depressed adults and normal preoperational children
Differences
between normal preoperational children and chronically depressed adults
Normal
Bifurcated cognitive emotional development
Maltreatment
and derailment of the maturational process among early onset chronic
depressives
Late
onset degeneration of cognitive emotional functioning
Chapter
4 Course Patterns, Comorbidity and psychological characteristics
Five
course patterns of chronic depression
Psychological
characteristics of untreated chronically depressed patients
Part
Two CBASP methods and procedures
Chapter
5 Strategies to enhance motivation for change
The
importance of motivation
Patient
misery and the negative reinforcement paradigm
Take
over pitfalls
Situational
analysis: exacerbation and resolution of psychopathology
SA
must be an existential encounter
Positively
addressing transference issues
Eliciting
a significant other list
Methodological
issues and rationale
Transference
hypothesis as tacit knowledge
Chapter
6 Elicitation phase of situational analysis
The
Coping survey questionnaire
Situational
description
Therapist
rules for administering step 1
Step
2: situational interpretations
Therapist
rules for administering step 2
Pathological
patterns arising during step 2
Step
3: Situational behaviour
Step
4: Situational actual outcome
Five
common errors
Step
5: Situational desired outcome
Step
6: Comparing the actual outcome to the desired outcome
Chapter
7 Remediation Phase of Situational analysis
Step
1: Revising irrelevant and inaccurate interpretations
Therapist
rules for administering Step 1
Step
2: Modifying inappropriate behaviour
Therapist
rules for administering step 2
Step
3: Wrap up and summary of situational analysis learning
Step
4: Generalisation and transfer of learning
Administering
situational analysis for anticipated future events
Chapter
8 Using the therapist-Patient relationship to modify behaviour
Determining
the patients interpersonal stimulus value
The
optimal Interpersonal style for the therapist
Disciplined
personal involvement with patients
Chapters
9-12 omitted due to clinical irrelevance to me
Chapter
13 Resolving Common Patient Problems and Crises
Summary
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.
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