Introduction

The format of this chapter is written to illustrate a single case administration of Cognitive Behavioral Analysis System of Psychotherapy (CBASP) to an early-onset, chronically depressed 39-year-old male. Large portions of the text consist of verbatim transcript interactions between the first author, JPM, and the patient. The verbatim exchanges are followed by comment sections to illustrate the underlying rationale guiding the therapist’s behavior. Our goal here is to help the reader get “a feel” for the way the CBASP model is administered to a chronically depressed patient. For a more in-depth review of the model, readers should consult the two major CBASP texts (viz. McCullough, 2000, 2006).

Briefly, the essential etiological predicament of the early-onset, chronically depressed patient arises from a developmental history of psychological insults and trauma (McCullough, 2008; Nemeroff et al., 2003; Wiersma et al., 2009) received at the hands of his or her significant others. These preadolescent or adolescent experiences leave early-onset patients sealed off behind a wall of pervasive interpersonal fear. The fear state frequently results in a lifetime pattern of interpersonal avoidance with little or no possibility of spontaneous remission (McCullough et al., 1990a, 1990b; McCullough et al., 1988). One consequence of the fear state is seen in an age-inappropriate level of cognitive-emotive functioning that is best described by Piaget (1926 /1923) as preoperational functioning (McCullough, 2000, 2006). Early-onset patients are not informed by environmental feedback, so they behave in the intrapersonal and interpersonal-social spheres with patterns of self-contained repetitiveness. They think in a precausal and illogical manner, leaping from premises to negative conclusions with no stops in between. In addition, they evince little emotional control and converse in a monologue fashion. At the outset of treatment, these patients frequently leave psychotherapists feeling helpless, incompetent, and frustrated. When administered medication alone—which is regrettably too often the case among U.S. psychiatrists—approximately 23% will remit (Keller, McCullough, et al., 2000; Kocsis et al., 2009), with relapse and high recurrence rates once medication is withdrawn (Thase, 1992). Approximately 45% to 50% of this patient population will not respond to medication alone. Recent research suggests that optimal treatment strategies should include medication and psychotherapy administered concomitantly (Keller, McCullough, et al., 2000; Schramm & Reynolds, 2010). Summarily, these childlike adult patients do not function adequately in the adult world and without proper treatment they are consigned to a lifetime of misery.

The goals of CBASP psychotherapy address the paramount intrapersonal and interpersonal dilemmas of the early-onset patient. Therapy must neutralize the interpersonal fear and instill felt interpersonal safety. This experience must then be generalized to others while interpersonal approach behaviors such as assertive strategies are taught. McCullough (2000, 2006) has posited that a major outcome goal is the acquisition of perceived functionality denoting that the patient is now able to recognize the consequences of his or her behavior. This achievement also implies that the patient is perceptually connected to his or her interpersonal environment and is now informed by the behavior of the therapist as well as others.

Case of Sam Smith

JPM administered the DSM-IV checklist for major depression (MD). Sam described his dysphoric mood state as (a) being present for the past 2 weeks. He had (b) lost interest and pleasure in all activities and reported (c) weight gain accompanied with bouts of eating even when he was not hungry; (d) he described being restless nightly during the middle of his sleep cycle, which disturbed his sleep, and he stressed that (e) he felt agitated and restless. Sam stated that he (f) felt “worthless” and he’d been having (g) significant difficulty concentrating and making decisions. When asked how long he’d felt just the way he was feeling now, he replied without hesitation: “For the past 2 years.” Sam said that he had experienced some relief for a 6-month period prior to the 2-year period, but a serious job crisis had precipitated the present chronic MD episode. As best we could determine, Sam’s feeling a “little better” lasted for several months (4 to 5 months) following a work promotion. Before that, Sam said that he’d felt down since graduating from college—the post-graduation period was diagnosed as his first MD episode; however, he said that this MD episode (that lasted about 12 years) had not been as bad as the one now. During college and high school, Sam described a course of DD with an onset age, as best we could determine, around 14 to 15 years. The DD symptoms he endorsed were (a) low energy/fatigue; (b) poor self-esteem; and (c) significant difficulty concentrating and making decisions. He also said that he had always had (d) insomnia problems, even in high school. JPM diagnosed Sam as a chronically depressed patient (Klein, 2008; McCullough, Klein, et al. 2003) with antecedent early-onset DD—a clinical course described by Keller and Shapiro (1982) as “double depression.” It should be noted that JPM ruled out the presence of bipolar disorder. The clinical course timeline is shown in Figure 5.1.

Figure 5.1 Clinical Course of Sam’s Early-Onset “Double Depression”

Comment

The patient left the session with a slim ray of hope, which was the best outcome JPM could have hoped to achieve during the initial session. Sam was referred to a psychiatrist who prescribed 50 mg of Zoloft (sertraline), which was titrated to 150 mg over the course of psychotherapy. He will stay on Zoloft after psychotherapy ends and for the foreseeable future.

Preoperational Functioning

McCullough (2000, 2006) described the primitive social-interpersonal behavior of chronically depressed adults and suggested that their cognitive-emotional-behavioral style mimics that of preoperational stage children (Piaget, 1926 /1923; Vander Molen, 2010). Sam described himself to JPM as a lonely individual and behaved as if he were interpersonally disengaged from others. Since he’d avoided the interpersonal environment for many years, his views about himself and others had never been accessible to hypothesis testing. It is not surprising that he behaved with JPM as a highly egocentric individual and as an adult who was undersocialized. Sam’s story at screening had a “sameness” quality about it regardless of whether he talked about the past, the present, or the future. The general theme could be depicted as follows: “This is the way things have always been in my life, this is the way they are today, and tomorrow will just be more of the same.” Time for Sam had stopped with the past, present, and future all collapsing into a landscape of rejection and failure. His self-description was analogous to a snapshot picture of reality—that is, it was frozen in time. Not surprisingly, he didn’t use logic or causal reasoning when he talked about himself. When he described the way people treated him, he saw no connection between what he did and the reactions of others. Sam talked to JPM in a monologic manner and with a style characterized by an absence of felt or expressed empathy. Treating Sam will be like starting a learning process with a 4- to 6-year-old child—yet, this individual is an adult.

Session 2: Significant Other History (SOH) and Post-Session Impact Message Inventory (IMI)

In this section, we discuss the purpose of the SOH and the IMI; additionally, we provide case examples to illustrate their use in therapeutic settings.

Comment

The SOH is designed to provide interpersonal emotional material that will inform the construction of the Transference Hypothesis (TH; McCullough, 2000, 2006). The TH is an emotionally derived interpersonal expectancy predicting how Sam is likely to behave while in therapy with JPM. The SOH evokes memories concerning each SO. As Sam and JPM reviewed each SO on the list, Sam was asked to describe the major influence (i.e., a stamp or mark) the SO has left on him (see McCullough, 2006) that shaped him to be the kind of person he is today. The Significant Other History procedure is shown below in Table 5.1.

Table 5.1 CBASP Significant Other History Procedure (SOH)

Comment on the SOH Content

Sam’s general emotional mood as he described his relationships with his significant others sounded like “the sadness of defeat.” He never described instances of feeling equal with his SOs. Ironically, the patient grew up around psychologically strong men and women—strong models to emulate. He married a psychologically strong woman. In addition, he bears no overt physical and psychological scars that frequently accrue from trauma—that is, severe physical, sexual, or emotional abuse within the family. Thus, we cannot pinpoint any specific trauma event to explain his refractory mood. So, what do we know based on his SOH? As best JPM could determine, Sam never attached in a positive emotional way to anyone in his family. He learned the social rules of morality and duty but never assimilated the “spirit of the law” that comes from feeling loved and protected by one’s caregivers. His SOH matches a pattern seen frequently among chronically depressed patients. The history reveals persons who have been the recipient of repeated and long-standing psychological insults (actual instances of emotional rejection, criticism, or negative judgment or repeatedly fearing that one will be rejected, criticized, or negatively judged) (McCullough, 2008). As noted earlier, Sam began psychotherapy interpersonally avoidant (i.e., detached and withdrawn). It was not difficult to hypothesize that what Sam would expect in a relationship with a male such as JPM would be an interpersonal replay of what he learned earlier from his father and grandfather—that being, an ineffectual model in the case of the father and expecting little tolerance for any sign of weakness or vulnerability (father, grandfather). JPM, after carefully reviewing the SOH material, constructed the following Transference Hypothesis (TH): If I let JPM get to know me (i.e., disclose myself and let him know how inadequate I feel), then JPM will judge me negatively, not like or respect me, because he’ll know that I’m a weak person.

The TH is hypothesized to be an important interpersonal expectancy that Sam will likely transfer to JPM. Thus, JPM begins treatment aware from the patient’s interpersonal history that he is unlikely to expect much help from his therapist. The TH will be used in subsequent sessions to make explicit to Sam that JPM is qualitatively different from his significant others.

Using the TH as an Assessment Measure

McCullough (2006) operationalized the TH using Shapiro’s Personal Questionnaire (PQ) paired comparison technique (Shapiro, 1961, 1964; Shapiro, Litman, Nias, & Hendry, 1973). The PQ was administered at the beginning of each session to reflect the perceptual success (or lack thereof) Sam achieves in emotionally discriminating JPM from his SOs (see McCullough, 2006, pp. 163–167). Four levels of treatment outcome are measurable using the PQ: illness level (score = 4: no change); minimal improvement (score = 3: some change evident); significant improvement (score = 2: partial response); and recovery level improvement (score = 1: remission response). Three 3-inch by 5-inch cards are used with the TH stated on Card #1 at an Illness level (More often than not, when I think about letting JPM get to know me, then I feel he will judge me negatively, not like or respect me because he’ll know that I am a weak person). The Improvement level sentence is written on Card #2 (Sometimes when I think about letting JPM get to know me, then I feel he won’t judge me negatively and that he will like and respect me and conclude that I’m not a weak person); and the Recovery level sentence written on Card #3 (More often than not when I think about letting JPM get to know me, then I feel he won’t judge me negatively, that he will like and respect me and conclude that I am not a weak person).

Following Session 2, JPM completed an Impact Message Inventory (IMI: Kiesler & Schmidt, 1993) on Sam. The IMI profile is illustrated in Figure 5.2. The patient obtained peak scores on two octants: the Hostile-Submission (H-S) octant (H-S items are as follows: Sam appears nervous around JPM; JPM should do something to put him at ease; Sam withdraws from important issues; Sam feels that he cannot do anything; Sam feels that assertion will lead to ridicule; Sam appears to feel inferior to JPM; Sam generally feels uneasy) and a peak score on the Submission (S) octant (S items are as follows: Sam makes JPM feel in charge; JPM feels dominant around Sam; Sam seems to be unable to disagree with JPM; Sam appears unable to stand up for himself; Sam appears to feel that he has few assets; Sam appears to feel that he has no answers; Sam appears to feel inferior to JPM). Kiesler (1988, 1996) defines interpersonal hostility as verbal or nonverbal stylistic attempts to avoid interpersonal encounter. Said another way, hostility as well as all the hostile octants on the interpersonal circle (Kiesler, 1983: i.e., H-D: Hostile-Dominant; H: Hostile; H-S: Hostile-Submissive) denote an avoidance-of-others interpersonal lifestyle in contrast to an interpersonal approach-of-others lifestyle reflected on the friendly side of the interpersonal circle (i.e., F-S: Friendly-Submissive; F: Friendly; F-D: Friendly-Dominant).

Figure 5.2 Sam’s Impact Message Inventory (IMI) Profile Scores FollowingSession 2

Source: Copyright © 1991 by Donald J. Kiesler. All Rights Reserved.

The potential problems that Sam’s interpersonal style presents to JPM are seen in the complementarity pulls (Kiesler, 1983, 1988, 1996) for interpersonal Hostility and Dominance. Complementarity, as defined by Kiesler (1983, 1988, 1996), means that H-S pulls for Hostile-Dominant responses (e.g., “Your efforts are disappointing, I’ll have to do it myself.”) and S pulls for Dominance (e.g., “Do what I say and you’ll be okay.”). It would be easy for JPM to deliver CBASP therapy and be pulled to react in a frustrated-angry complementary manner (Hostile-Dominant) in the face of Sam’s detached and withdrawal style; likewise, assuming a “take charge” complimentary role (Dominance) given Sam’s Submission style will also be a strong temptation. Both of these therapist behaviors have been described elsewhere by McCullough (2000, 2006) as “lethal” because they simply reinforce the old damaging interpersonal expectancies. Thus, the interpersonal goals for JPM are to remain on the Friendly side of the interpersonal circle and to avoid the complementarity pulls for Hostility and Dominance (see McCullough, 2000, p. 178).

Kiesler (1983, 1996) describes the interpersonal outcome goals for psychotherapy for these patient types. The goals lie on what Kielser calls the nadir octants (see Figure 5.2) that stand directly opposite Sam’s original (avoidance) peak octants; nadir octants for Sam lie on the Friendly-Dominant (F-D) and the Dominant (D) octants, respectively. These octants reflect “approach” behaviors such as taking interpersonal charge of situations (F-D: “I’m strong and will impress you with my skills.”) and the actualization of more interpersonal control (D: “I can take care of my life now”).

Sam was also given the CBASP Patient’s Manual (McCullough, 1993) at the end of Session 2 and asked to read the material prior to the next session. The manual would be discussed at that time. He was also told that he and JPM would begin to do situational analysis (SA), which is discussed at length in the manual.

Session 3: Discussion of the Manual and the First Situational Analysis (SA)

Table 5.2 Coping Survey Questionnaire (CSQ) for Situational Analysis^a

Step 1 of SA: Elicitation Phase

Step 2 of SA: Elicitation Phase

Related posts:

Introduction: Evidence-Based Practice for Major Depressive Disorder One Size Does Not Fit All: Cultural Considerations in Evidence-Based Practice for Depression Cognitive Behavior Therapy for Depressed Adults Cognitive Behavior Therapy Treatment for Adolescents Behavioral Activation for Depression – THE INTERMEDIATE STAGE OF SUPERVISION

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