Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy

McCullough anad co-author Marvin Goldfried have produced a treatment manual for the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), a new form of therapy for chronic depression. Many readers may be deterred by the description of it as a treatment manual and conclude that it is not of any further interest. Some authors have held that the trend toward manualized approaches to therapy is a bad thing for psychotherapy and leads to impoverished and perhaps hopelessly ineffective treatment.1 Those of us trained in cognitive behavioral models accept and value the movement. However, cognitive therapists might ask why we would need a new manual on treatment of depression. After all, didn't Beck2 set the standard for treatment manuals with the classic Cognitive Therapy of Depression? Furthermore, hasn't cognitive therapy demonstrated its efficacy in treatment of depression? This book speaks to these questions and makes it clear that is has an important place because it offers a new conceptualization that is testable and appears to be an effective method for treating patients with a frustrating, resistant, life-threatening condition. McCullough points out that neither standard cognitive therapy using Beck's model nor interpersonal therapy was specifically designed to deal with chronic depression. The book summarizes outcome data, which show an impressive response rate for CBASP especially when combined with antidepressant medication. The model of therapy is based on an etiological theory of chronic depression that is deceptively simple. McCullough first explains what led to development of the model he will work with throughout the book. He draws from Piaget and argues that the chronically depressed are functioning at a preoperational level of cognitive processing. This leads to patients not connecting their actions with the consequences in their lives. This disconnection is the fatal flaw in chronic depression, leading to the hopelessness and helplessness that characterize the disorder. According to McCullough, individuals with early-onset chronic depression have never reached a stage of formal operations, and those with late-onset chronic depression have lost the ability to think this way in interpersonal contexts. The goal of therapy in part, then, is to drag the patient to the point where he can function using formal operations and so understand the consequences of his own behavior. McCullough offers tools to facilitate this change and conceptualizes the learning that must take place in the language of operant conditioning. Motivation to change is elicited by skillful use of negative reinforcement. The principal technique of CBASP is the situation analysis, or SA. The book spells out in detail what is involved in conducting SAs and the rationale for each step. McCullough frequently points out mistakes of novice CBASP therapists and the traps that anyone trying to do this type of therapy will encounter. The most common one is doing the work for the patient. He simply enjoins us not to do it. The reader is given examples and specific questions to use in conducting the SA as well as a method to evaluate the patient's progress in learning to do these on his own. We are led to understand that only by therapists' shaping behavior and applying consequences, primarily in the form of negative reinforcement, will patients learn how their behavior affects their environment and begin to think in the formal operations mode. Only then will they realize they have the power to achieve their own desired outcomes in life and begin to relate to others in an empathetic way. Those of us who have cognitive-behavioral backgrounds do not focus on transference and will find McCullough's model and discussion clear and useful. My guess is readers with psychodynamic backgrounds will find his ideas disturbingly simplified. The therapy model does include the idea that learning from earlier relationships is played out in the therapy relationship. McCullough does suggest developing a hypothesis about how this will happen, based on data gathered in an early session. Unfortunately, he does not explain how to formulate the hypotheses. When transference hot spots do occur in session, the therapist uses the opportunity to teach the patient to discriminate between the different relationships. This is called an Interpersonal Discrimination Exercise or IDE. As in the SA, we are applying consequences to the patients' behavior in order to teach them how their behavior affects others and to lead them toward interacting with others in an empathetic formal operational manner. McCullough brings in a unique idea about use of the therapist's self in the therapy. He describes Kiesler's model of interpersonal interactions. Using this model and a measure of interactions, the Impact Message Inventory, McCullough describes how the typical chronically depressed patient will interact, and the pulls for the therapist to respond in certain ways. However, the response must not be the automatic one because that will lead to failure of the therapy. Instead, a disciplined use of self in the therapy, guided by an understanding of the psychopathology, is recommended. Let me end where I began: Do we need another treatment manual? McCullough reflects that the experience of treating the chronically depressed can be likened to pouring energy down a black hole. Since he has a new model and a method with which to approach this needy population, and the evidence seems to suggest it may work very well, I for one am encouraged and feeling less hopeless already. My answer is a resounding yes.