Updated July 3, 2017

James P. McCullough, Jr., PhD

Introduction: I returned from Europe and felt it would helpful if I defined some terms while providing an origin for the term, a rationale for the term and a definition that I think is currently appropriate. These terms below have become an integral part of our CBASP vocabulary. Here goes:

Acquisition Learning: The therapist’s role in CBASP Psychotherapy is choreographing consequences for behavior so patients learn to take care of themselves. Learning is slow over sessions and has highly variable rates across patients. Go slow with your treatment administrations and be sensitive to your patient’s learning pace. The core assumption of the CBASP Model is that if patients learn the lessons of CBASP, they will overthrow the chronic disorder.

Caveat: JPM thinks that chronic depression can be effectively managed but is never finally cured. Thus, patients must be taught that practicing the learning lessons of CBASP must become a lifetime homework assignment in order to avoid a recurrence of the psychopathology they have worked so hard to overcome.

Basic Assumption of CBASP for the Chronic Depressive Psychopathology: Wherever there is BEHAVIORAL AVOIDANCE, a learned fear is driving it. The Transference Hypothesis (TH) sentence makes explicit the major core-fear avoidance strategy of the patient.

CBASP (Cognitive Behavioral Analysis System of Psychotherapy): An interpersonal-acquisition learning model of psychotherapy that seeks to empower the felt helplessness of the patient by demonstrating to the individual that their behavior has effects on themselves as well as others. The attack on patient helplessness is choreographed by the CBASP therapist who arranges behavioral consequences and contingencies during the sessions so patients learn the contingency nature of the model. Consequence/contingency learning is the healing motif of CBASP psychotherapy.

Contingent Personal Responsivity (CPR)CPR is a 4-step technique that was originally designed to consequate [administer personal consequences for] the behavior of “Pre-therapy Patients” who behave in ways that preclude/prevent clinicians from conducting psychotherapy. New learning cannot take place in the presence of these maladaptive behaviors. Examples of these behaviors might be remaining mute/silent during the session; refusing to make eye-contact with the therapist; talking “over” the therapist, hence making it impossible for the therapist to get a word in edge-wise; changing the subject frequently when difficult issues arise; protesting loudly about one’s misfortunes; making hostile comments about the competency of the clinician, etc. Maladaptive behaviors such as these patterns prevent learning from taking place in the session; in short, these behaviors short-circuit the effectiveness of treatment and make therapy impossible. CPR is a clinician activity whereby the therapist provides feedback to the patient for a specific behavior – said another way, it is a response where the therapist “becomes a problem” for the patient and the problem is presented in a contingent/consequating manner. Several examples of CPR are provided: “When you talk over me you render me helpless;” “Why are you beating up on me with your hostile comments?” “Your constant protests about the unfairness of life keep me at a distance and makes our work impossible. Why do you treat me like this?” etc. Once the patient’s pinpointed maladaptive behavior is decreased to manageable levels, and verbal control and the focusing capability of the patient have been established in the session, then CPR administration is terminated and treatment can begin.

Counter-conditioning: Replacing a behavior in the presence of a specific stimulus with another behavior (e.g., replacing avoidance behavior with approach behavior in the presence of dyadic intimacy, personal disclosure, making mistakes, or expressing negative affect to one’s therapist). Disciplined Personal Involvement (DPI): DPI is a personal involvement dyadic-style of relating to the patient (objective counter-transference strategy) with a strong emphasis on “discipline.” The discipline component of DPI means that the patient’s well-being is always the central concern of the clinician. DPI is designed by the therapist as one means to modify patient behavior and this type of therapeutic role makes CBASP unique in the field. The role DPI takes in the dyad is determined by (1) the Transference Hypothesis arising from the Significant Other History patients reported on during session two; (2) the patient’s interpersonal impacts on the clinician (e.g., Submissive, Hostile-Submissive and Hostile impacts, etc.) that are identified by the therapist-rated peak scores on Kiesler & Schmidt’s Impact Message Inventory (IMI). The IMI is completed at the end of session 2. DPI is an “objective” type of counter-transference that involves verbal and nonverbal interpersonal impact reactions to what the patient does and says. JPM describes DPI as “a way of dyadic being in the session” for CBASP therapists.

Dyadic Empathy Exchanges: Two-way or two-person exchanges (Person x Environment) occurring between the patient and therapist suggesting that the patient is functioning in a formal operational manner (abstractive thinking) and is able now to attend to relevant aspects of the therapist’s behavior. Usually occurs during the latter stages of therapy.

Essential Treatment Goals of CBASP Psychotherapy: (1) The achievement of dyadic safety between therapist & patient: CORE PROBLEM ONE is a pervasive fear-avoidance state at the beginning of therapy which stems from a history of early-developmental maltreatment; and (2) perceptually connecting the patient with the patient’s social environment: CORE PROBLEM TWO is defined as the perceptual disconnection from the interpersonal environment signaling that one’s social environment (including the therapist) does not have any informing influence on one’s behavior – usually present during the early stages of treatment. CBASP Assumption: Persistent Depressive Disorder is maintained by these two pathological core problems the patient has not been able to resolve. Successful treatment requires that both problems must be resolved.

Hot Spot: An instance during the session where the core-fear implicated by the Transference Hypothesis arises. If appropriate, the Interpersonal Discrimination Exercise (IDE) may then be administered.

Impact Message Inventory: Form II Octant Scale Version (IMI): DJ Kiesler & JA Schmidt (1993) validated interpersonal measurement instrument used to quantify the interpersonal circle impacts the patient has on the clinician. The IMI is usually completed on the patient after Session 2. The instrument is used as one means to define the clinician’s role with the chronic patient.

Interpersonal Discrimination Exercise (IDE): IDE is a four-step exercise designed to help the patient DISCRIMINATE the therapist from Significant Others who have hurt the individual. The goal of the IDE is to create dyadic safety (GOAL ONE OF CBASP). The IDE is administered in approximately 30% of the therapy sessions – more frequently in the beginning and less frequently later in treatment. The four IDE steps should be learned to criterion so that the patient can self-administer the IDE on cue from the clinician and complete the four steps with no assistance from the therapist.

Motivational Variables in CBASP
(1) One motivation variable is the patient’s failure to achieve his or her Desired Outcome during an SA exercise. The therapist should allow the patient experience the distress present in this failure and then experience the ‘relief’ that comes when a badly managed situation is repaired during the Remedial Phase of SA. This is a negative reinforcement situation (R-) created by the clinician whereby a negative feeling state is alleviated when more adaptive behavioral strategies become available.
(2)  Secondly, use any termination of felt distress in the session as a moment to make explicit or clarify what has led to the termination of discomfort. Remember, whatever leads to the termination of a felt distressful state of affairs is a negative reinforcer [e.g., you get a headache, you then reach for an aspirin or some pain reliever].Whenever patients come in feeling better, our first question must be “WHY?” Then, highlight whatever patient behaviors brought them relief and be on a constant watch for future ‘relief moments.’
(3) Negative reinforcement moments are more powerful than positive reinforcement (R+) in psychotherapy as they signal felt relief and the termination of distress! You want to produce patients who can terminate their own pain and improve their negative states of emotionality.

Pace of Treatment Administration: As much as possible, work at the pace the patient can manage. Walking at the pace of the patient without pushing, pulling, fussing, preaching or pleading is the most desirable therapist behavior. The chronic patient patient is very difficult and functions in a qualitatively different manner/mode/tempo compared to their therapist.

Persistent Depressive Disorder (Dysthymia: Chronic Depression) [PDD]: DSM-5 defines Persistent Depressive Disorder (Dysthymia) as a depressive course that occurs in adults (> 21 years of age) most of the day, for more days than not, for at least 2 years; or at least 1 year for children and adolescents. PDD is a new chronic depression category in the latest DSM 5. The ICD-11 [World Health Organization] diagnostic nomenclature is currently being revised.

Preoperational Functioning of the Patient: Describes a chronically depressed adult who functions in the social-interpersonal arena in a child-like manner even though he or she is a chronological adult: a) patients do not feel safe in interpersonal relationships, b) they are not perceptually connected to the social environment meaning that the behavior of others has little to no informing effect on what patients do [i.e., “they live in their head”], c) the patient does not function interpersonally using formal operational thought (abstractive thinking), d) the patient does not function employing causal or logical reasoning, e) the person evinces very little emotional control, f) the person does not report a perceptual future – rather, the present is mostly a replay of the past and the future bodes only more of the same and finally, g) the patient is excessively egocentric. These characteristics of the chronic patient make treatment management difficult because, in the beginning, the patient is functioning on a level significantly below that of his or her therapist. This fact makes it easy to “over-shoot” or “over-estimate” the patient’s ability to assimilate or understand the subject matter of CBASP therapy.

Significant Other History (SOH): The SOH is designed primarily for the benefit of the therapist, not the patient. Its primary goal is to help the clinician define his or her dyadic role. The patient is told this fact at the beginning of the social-interpersonal history exercise in Session Two: “The SOH is constructed to enable the therapist to know you better – it will not help you to feel better.” The SOH is administered during Session 2 and examines 4-5 Significant Other (SO) persons in the patient’s life. The exercise is a Pavlovian memory task requiring the patient to focus on one Significant Other at a time and recall positive or negative memories about what growing up or being around the individual was like. After a few memories are recalled and it is clear that the patient is “personally experiencing the memories,” the therapist then asks, “What do you take from this relationship that has influenced you to be who you are right now?” or, “What is the major stamp or legacy of influence that you take from this person that has informed the direction your life has taken?” In JPM’s earlier writings, the “stamp” has been labeled a causal theory conclusion.

Situational Analysis (SA): SA is a 5-step exercise with the chief purpose of teaching chronic patients that their behavior has consequences. Its Piagetian ‘mismatching’ nature also teaches preoperational patients to think in a formal operational manner; that is, to be able to take a perceptual step back from an interpersonal situation and to view how they behaved with another person and to finally enable them to consider an alternative means to achieve a Desired Outcome – this is abstract thinking. SA is THE MAJOR CBASP change technique and it should be administered in approximately 75 % of the sessions. Doing SA over repeated sessions also leads to a perceptual set of perceived functionality (a formal operational skill) which is the learned ability to identify the consequences one produces with others (GOAL TWO OF CBASP).

Caveat: Revising the SA procedure by inserting maneuvers (e.g., Impact Message Inventory [IMI] ratings and discussion of situational interpersonal impacts, etc.) in the middle of the 5 steps, violates the core behavior-consequence integrity of SA, negates the primary reason SA was developed, and makes the 5-step method tedious and difficult to learn! Modifying the SA procedure compromises the CBASP model in significant ways.

Role playing is frequently employed at the end of an SA exercise to shape up newly learned behavioral skills – particularly assertive behavior skills [i.e. saying what I want and don’t want & doing what I want and not doing what I don’t want]. The most optimal/best outcome for SA training is that the patient learns the five SA steps to criterion so they can self-administer SA with no assistance from the clinician.

Situational Analysis (FUTURE): Future SAs may be used to prepare patients to deal effectively with upcoming/future interpersonal encounters. Three steps are taken in this preparatory exercise: (1) A Desired Outcome for the encounter is pinpointed; (2) a brief Action Read is constructed (i.e., “Focus!” “Say what I want;” “Ask what I want;” etc.); finally, (3) behavioral practice is conducting so the patient has the requisite skills to obtain the Desired Outcome. The next session must be used to review the effectiveness of the patient’s behavior during the situation pinpointed in the previous Future SA.

Structure of CBASP Psychotherapy: The CBASP model is an acquisition learning structure of psychotherapy which qualifies the model to be a psychological experiment. The patient’s task is to learn the “subject content” of the model to criterion and to learn to apply the new cognitive and behavioral skills in daily living in order to overthrow their chronic depression dilemma. There are three learning questions that CBASP therapists must address: (1) What is one trying to teach? (2) How much learning is the patient achieving as therapy progresses? and, (3) How does the amount of learning achieved relate to the reduction of the depressive symptoms (the outcome-of-therapy variable and the empirically-phrased question).

Transference Hypothesis (TH): The clinician, being very sensitive to his or her gender in the construction of the TH, reviews the several stamps or causal theory conclusions obtained during the SOH to determine if there is a ‘common maltreatment theme’ running through the Significant Other History material. Hopefully, ONE CORE FEAR-AVOIDANCE HYPOTHESIS will be apparent that can then be represented by one Transference Hypothesis sentence. The sentence is stated in such a way that describes how the core-fear situation (“hot spot”) will produce the feared consequence. For example: “If I disclose anything about my personal feelings to Dr. Smith, then he will ridicule me or tell me that I am stupid.” The “if this….then that” organization of the TH sentence helps the clinician understand the core-fear and hurtful consequence dilemma that the patient likely will experience.

Transference Hypothesis Domains: The therapist reviews the causal theory conclusions or stamps or legacy of influence themes, and pinpoints the core-fear TH of the patient placing the TH in one of four interpersonal domains: (1) relational dyadic intimacy or closeness; (2) personal disclosure of emotional need; (3) making mistakes in treatment; and, (4) the expression of negative emotionality.

Caveat: No more than one TH is formulated and used during the process of treatment. The reason for this limitation is that constructing more than one TH becomes difficult to administer and easily over-burdens the therapist with yet another task he or she must do. We have found that one TH when covered thoroughly over the course of treatment is sufficient to achieve a nice discrimination of the therapist from maltreating Significant Others.

Patient’s Final Exam at the end of treatment:

  1. Do one Situational Analysis on one interpersonal situational event with no assistance from the therapist. (Criterion Answer: 5 correct steps completed with revisions, if necessary, with no help from the therapist. A step is incorrect if the clinician must provide assistance.)
  1. Do an Interpersonal Discrimination Exercise (IDE) on the clinician and maltreating Significant Others with no help from the therapist. (Criterion Answer: 4 correct steps completed with no help from the therapist. A step is incorrect if the clinician must provide assistance.)

Suggested Reading: JP McCullough, Jr., L Schramm & JK Penberthy (2015). CBASP as a Distinctive Treatment for Persistent Depressive Disorder. London: Routledge Press. [However, I hear that the German translation is poorly done.]

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