by Michael D. Anestis, M.S.
For a beginning therapist, it is not at all uncommon to walk into the therapy room with the fear that you will not remember what you are supposed to do - that you will forget the manual entirely, make things up as you go along, and fail to help your client's symptoms improve. This rarely actually happens, mind you, but like any negative automatic thought, its validity is not proportionate to its power. In my first days of training, I was fortunate in this respect, as my initial supervision taught me a therapeutic intervention known as Cognitive Behavioral Analysis System of Psychotherapy (CBASP; McCullough, 2000). In this article, I will discuss the emerging evidence that CBASP, created by James McCullough of Virgina Commonwealth University, is an effective psychotherapeutic approach, particularly for chronic depression, but first I want to explain the steps involved in the process.
CBASP is easily the most highly structured approach I have learned. The entire intervention revolves around worksheets that are aimed to discuss the client's interpretations, behaviors, and desired outcomes in specific, quick interpersonal interactions. Essentially, this is an exercise in situational analysis and the underlying assumption, quite simply, is that by increasing the frequency with which an individual attains what she wants in situations, mood will improve and depressive symptoms will fade.
Step 1 - Select an interaction from the previous week. The situation should be short, lasting minutes rather than hours. Describe this situation in factual terms (no interpretations of meaning) in no more than three or four sentences.
- Clients often resist focusing on such a small slice of time. After all, situations relate to one another and problematic patterns have emerged in their lives. The importance of doing so, however, is to help the client change specific thoughts and behaviors. Not everything can be changed at once, but developing a pattern of recognizing specific ways to change can lead to general change across situations.
- Clients also often struggle to speak only in factual terms. Saying "he treated me poorly" does not work here. Instead, the client should say "I gave cashier a $20 bill and he only gave me change for $10." The second example still involves poor treatment, but it provides detailed facts the client and therapist can work with later on in the worksheet.
Step 2 - What was your interpretation of the situation?
- Here, the client is instructed to write down three or four automatic thoughts that she experienced during the course of the specific situation. It is important not to include thoughts prior to or after the situation.
- Examples of interpretations experienced during an interaction could be "she hates me," "I'm horrible at this, "why do I always fail?" or "he's a jerk."
Step 3 - What were your behaviors?
- Here again, the client is instructed to list several examples. Behaviors include eye contact, tone of voice, delay in response, body language, and what was said during the course of the interaction.
- The client is encouraged to be thorough here. For example, the phrase "I believe you" can mean different things if an individuals waits 10 seconds in silence before saying it, says it while rolling his eyes, or smiles while saying it. The details will inform later steps in the worksheet.
Step 4 - Desired outcome - What did you want to happen in this situation?
- This may be the most difficult step in CBASP. Desired outcomes are limited to things that the client can actually control. In other words, the desired outcome can not be something that is physically impossible. Even more importantly, the desired outcome can not be something that the client wanted somebody else to think, do, or feel.
- It is perfectly natural to desire other people to feel or do things, but CBASP teaches the principle that, even if a situation is navigated perfectly, other individuals may respond poorly. As such, a desired outcome could be "I wanted to do everything in my power to increase the chance that he would agree with me," but it can not be "I wanted him to agree with me."
- This is often frustrating for the client. At times, he may even believe that he is being blamed for all that goes wrong. This is not the case, however. Instead, the client is being taught to simply focus on things over which he has control so that things outside of his control no longer make him feel as though he has done something wrong.
Step 5 - Actual outcome - What actually happened?
- Here, the client briefly explains what actually happened and declares whether or not this was consistent with her desired outcome.
Step 6 - Remediation
- During the remediation phase of CBASP, the client and therapist review each interpretation and behavior listed on the worksheet and determine whether it was helpful or hurtful with respect to increasing the likelihood that the client would obtain her desired outcome in that situation.
- For interpretations and behaviors that were helpful towards obtaining the desired outcome, time is spent discussing why it was helpful, what led the client to choose an adaptive behavior, and what the client might do to increase the likelihood that she will use this same approach in future situations.
- For interpretations and behaviors that were hurtful towards obtaining the desired outcome, helpful alternative approaches are designed. This is a particularly useful exercise, as hurtful patterns are quickly recognized and the client thus practices changing bad habits that have become obstacles in his attempts to attain desired outcomes.
Some clients become skilled at this approach quite quickly while, for others, it takes more time. Regardless of the speed of skill acquisition, CBASP involves a significant amount of homework. Clients are given numerous worksheets and told to fill them out as often as possible, immediately following the situations they choose. The closer to the actual occurrence the better. This is true for two reasons: the situation is remembered more accurately and the benefits of alternative approaches are reinforced because the worksheet often creates an increase in positive affect and/or a decrease in negative affect when filled out close enough to the event that the client is still upset. During sessions, the client and therapist will go over one or more of the worksheets completed throughout the week, discussing any difficulties the client encountered, training further in particular skills, and reinforcing the efforts of the client.
Building off of the Keller et al (2000) findings, Schatzberg and colleagues (2005) found that, for individuals who do not respond to nefazodone, switching to CBASP results in significant clinical improvement. Similarly, for individuals who do not respond to CBASP, switching to nefazodone results in significant clinical improvement. Klein et al (2004) found that CBASP is an effective maintenance treatment. In this study, participants took part in 16-20 sessions during the course of a 12-week treatment period and six sessions during a 16-week continuation period. Participants in the maintenance condition then received an additional 13 sessions during a 52-week maintenance period. Results indicated that participants in the maintenance condition experienced a greater average reduction in depressive symptoms and were less likely to relapse.
Cukrowicz and Joiner (2007) created a computer protocol based upon CBASP and tested its utility in a sample of undergraduates. They compared the effects of the CBASP computer protocol to the effects of simply providing education on the nature of depression and anxiety and found that, while both education alone and education with CBASP significantly reduced depressive and anxiety symptoms, the computer CBASP condition experienced greater levels of improvement. Importantly, only individuals with sub-clinical levels of depression and anxiety were included in the study, so further research is needed to determine the potential utility of a computer-based CBASP intervention in clinical populations, but these results are highly promising.
Interestingly, in light of Friday's article on therapeutic alliance, Santiago and colleagues (2005) found that therapeutic alliance and the ability to use the skills taught in CBASP both independently contributed to decreases in depressive symptoms. Arnow and colleague (2007) compared individuals in CBASP alone, nefazodone alone, and combination treatment on dropout rate and found that individuals in the combined treatment were significantly less likely to drop out of treatment than were individuals in the medication only group and did not differ in their dropout rate compared to individuals in the CBASP only group. For individuals receiving only CBASP, a poor therapeutic alliance predicted premature dropout (and early response to treatment did not).
Additional theoretical work has been done on CBASP as well. Sperry (2005) provided a case example of CBASP in individual and couples counseling as a method to improve communication on medical issues. Additionally, Sperry (2007) provided a case example of the utility of CBASP in managing spiritual issues that can arise during the course of therapy (e.g., "God hates me"). Future empirical testing of these ideas is necessary before conclusions can be drawn regarding the utility of CBASP in these particular domains, but this early work provides an interesting foundation.
As a therapist, I admire CBASP for its structure and its ability to efficiently convey important ideas. As a researcher, I admire the emerging empirical evidence that CBASP is not only effective, but demonstrates its effects in a population that is often treatment resistant.
If you would like to learn more about CBASP, a variety of resources are available. We recommend the following:
Hard Copy Books:
Simple Treatments for Complex Problems: A Flexible Cognitive Behavior Analysis System Approach To Psychotherapy
Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP)
Patient's Manual for CBASP
Treating Chronic Depression with Disciplined Personal Involvement: Cognitive Behavioral Analysis System of Psychotherapy (CBASP)
Kindle:
Treating Chronic Depression with Disciplined Personal Involvement: Cognitive Behavioral Analysis System of Psychotherapy (CBASP)
Additional resources are available through our online store.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
