Major depressive disorder (MDD) is a common disorder which is usually associated with severe and persistent symptoms. The global prevalence of MDD is 1.6% in men and 2.5% in women (Ayuso-Mateos et al., 2000). The lifetime prevalence in the general US population is 16.2% (Kessler et al., 2003). Individuals between 18-29 years have the highest cumulative lifetime prevalence in comparison to all other age-groups. The rate of MDD diagnosis is particularly high in younger females (Wittchen et al., 1992; Kessler et al., 1994; WHO, 2004; Satyanarayana et al., 2009). MDD is the 4th leading cause for "years of healthy life loss" in high- and middle-income countries. The WHO predicts that by 2020 MDD will move upwards to be the 2nd cause (WHO, 2004). The impact of MDD on quality of life is equivalent to that of severe physical illness, such as cancer, diabetes mellitus and chronic obstructive pulmonary disease (Sintonen, 2001; Saarni et al., 2006). In addition, 9-23.0% of individuals with one or more chronic medical conditions suffer of co-morbid depression. Consistently across countries and different demographic characteristics, respondents with depression co-morbid with one or more chronic physical conditions have the worst health scores of all disease states (Moussavi et al., 2007; Trivedi et al., 2009; Satyanarayana et al., 2009). Suicide and chronicity are significant further threats of MDD. Patients with more severe recurrent and/or chronic MDD die up to 15% by suicide (APA, 2000; Wahlbeck and Mäkinen, 2008; Satyanarayana et al., 2009). In one of three cases MDD leads into a chronic course, particularly when antecedent dysthymia is present (Keller et al., 1982; McCullough et al., 1996; Costa and Silver, 1998). A recent Canadian community health survey with inclusion of 36984 individuals aged 15 years and older reports the life-time prevalence of chronic MDD to be 2.7%, representing 26.8% of all individuals affected by MDD (Satyanarayana et al., 2009). The prevalence of dysthymia with or without superimposed major depressive episodes is estimated to be approximately 3%, the lifetime prevalence 6%

**1. Introduction**

(American Psychiatric Association, 2000).

### **Cognitive Behavioral Analysis System of Psychotherapy (CBASP): A Disorder-Oriented, Theory-Driven Psychotherapy Method from the "Third Generation" of Behavior Therapy Models, Designed for the Treatment of Chronic Depression**

Dieter Schoepf¹ and Peter Neudeck²

*1University Clinic Bonn, Department of Psychiatry, CBASP-Centre of Competence ²Practice of Behavior Therapy Köln/Berlin Germany*

#### **1. Introduction**

Major depressive disorder (MDD) is a common disorder which is usually associated with severe and persistent symptoms. The global prevalence of MDD is 1.6% in men and 2.5% in women (Ayuso-Mateos et al., 2000). The lifetime prevalence in the general US population is 16.2% (Kessler et al., 2003). Individuals between 18-29 years have the highest cumulative lifetime prevalence in comparison to all other age-groups. The rate of MDD diagnosis is particularly high in younger females (Wittchen et al., 1992; Kessler et al., 1994; WHO, 2004; Satyanarayana et al., 2009). MDD is the 4th leading cause for "years of healthy life loss" in high- and middle-income countries. The WHO predicts that by 2020 MDD will move upwards to be the 2nd cause (WHO, 2004). The impact of MDD on quality of life is equivalent to that of severe physical illness, such as cancer, diabetes mellitus and chronic obstructive pulmonary disease (Sintonen, 2001; Saarni et al., 2006). In addition, 9-23.0% of individuals with one or more chronic medical conditions suffer of co-morbid depression. Consistently across countries and different demographic characteristics, respondents with depression co-morbid with one or more chronic physical conditions have the worst health scores of all disease states (Moussavi et al., 2007; Trivedi et al., 2009; Satyanarayana et al., 2009). Suicide and chronicity are significant further threats of MDD. Patients with more severe recurrent and/or chronic MDD die up to 15% by suicide (APA, 2000; Wahlbeck and Mäkinen, 2008; Satyanarayana et al., 2009). In one of three cases MDD leads into a chronic course, particularly when antecedent dysthymia is present (Keller et al., 1982; McCullough et al., 1996; Costa and Silver, 1998). A recent Canadian community health survey with inclusion of 36984 individuals aged 15 years and older reports the life-time prevalence of chronic MDD to be 2.7%, representing 26.8% of all individuals affected by MDD (Satyanarayana et al., 2009). The prevalence of dysthymia with or without superimposed major depressive episodes is estimated to be approximately 3%, the lifetime prevalence 6% (American Psychiatric Association, 2000).

Cognitive Behavioral Analysis System of Psychotherapy (CBASP):

A Disorder-Oriented, Theory-Driven Psychotherapy Method from the "Third Generation"… 89

over a 37-month period. Outpatients with non-psychotic MDD with- and without antecedent dysthymia, and with other co-morbid mental and general medical conditions were included. The evaluable MDD population consisted of 2876 patients (72%) with a mean onset age of 25.3 years. The number of MD-episodes was 6, the length of the current MDepisode was 24.6 month, the length of illness was 15.5 years, and the number of concurrent medical conditions was 3.3. Cognitive therapy was available as either a switch from or augmentation of citalopram in the second step of treatment. Based on the first (n=3671), second (n=1439), third (n=390) and fourth (n=123) treatment steps, the corresponding remission rates were 36.8%, 30.6%, 13.7% and 13.0%, respectively, with an overall cumulative remission rate of 67%. In step-2 remission rates between cognitive therapy and medication in either the switch or augmentation strategies did not differ, although participants in cognitive therapy augmentation had a longer time to remission of 55 days compared to those in medication augmentation with 40 days. Treatment resistance was associated with more concurrent axis I or III co-morbid conditions, socioeconomic disadvantage, chronicity and melancholic or anxious features. With regard to longer-term outcomes a substantial number of patients relapsed. The cumulative proportion of participants without relapse during the naturalistic 12 month follow-up was highest in step 1 remitted patients compared to step 2 remitted patients. In comparison, those patients who were only partially remitted in step-1 and did not enter step-2 treatment had a 50% decreased survival rate compared to patients that remitted at step 1. In general, those patients who required more treatment steps had higher relapse rates during the naturalistic follow-up phase (Rush et. al 2006a, 2006b). The implications of STAR\* D are that at present there is a substantial lack of knowledge how to choose among and sequence the different available treatment strategies, how to deliver or implement these treatments, and how to identify which treatments will most benefit particular patients. It is also unknown, whether different strategies or tactics have better outcomes based on different treatment settings (Rush et al., 2009). Future treatment expectations suggest combined outcome criteria that target on complete syndromal remission and complete restoration of social functioning (Nelson et al., 2008). While the increase of the range of medications, biophysical interventions, comprehensive depression-targeted psychotherapies and somatic treatment is encouraging, effective treatment to achieve complete remission and, ultimately, long-term, successful outcomes of social functioning is an unsolved problem and remains an outstanding need in psychiatry, particularly in chronic MDD with antecedent dysthymia

(McCullough et al., 1996; Kessler et al., 2003; Schoepf et al., 2007; Nelson et al., 2008).

In 2006, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) was officially introduced in Germany for the specific psychotherapeutic treatment of chronically depressed patients. CBASP is developed by James P McCullough Jr (USA) as a specific outpatient protocol that integrates interpersonal and cognitive-emotional strategies. McCullough started his clinical carrier as a "first-wave" operant behavior therapist in the early 70th of the last decade. His work is deeply influenced by Skinner's tradition of radical behaviorism. CBASP addresses directly the specific intrapersonal and interpersonal symptoms of MDD with antecedent dysthymia (double depression). From a perspective of behavior therapy, behavior theory approaches from original and revised models of behavior therapy are incorporated with a strong disengage from the pure cognitive content focus of cognitive therapy. In addition, CBASP uses elements of "third wave" of cognitive behavior therapy methods that

**1.3 Cognitive Behavioral Analysis System of Psychotherapy (CBASP)**

#### **1.1 Diagnostic issues of chronic MDD**

Chronic depression is defined as unipolar depressive disorder lasting two or more years with less than a two-month period during which the individual reports no symptoms. The rating for chronicity is contingent upon the density of symptoms at the time of assessment, every day in MDD and more days than not in dysthymia. Manic, mixed or hypomanic episodes are listed as exclusion criteria. Coincidences of symptoms with other psychiatric disorders frequently occur (American Psychiatric Association, 2000). In the DSM-IV mood disorders field trial seven chronic course descriptions were reliable differentiable (Klein, 1992; Keller et al., 1995; McCullough et al., 1996). The most common condition is represented by patients with early onset dysthymia that suffer the additional burden of either a more severe and pervasive major depressive episode or recurrent major depressive episodes with or without interepisode recovery (double depression), accounting for up to 75% of the total numbers of affected individuals (Klein et al., 1996). Double depression represents the simultaneous occurrence of two unipolar depressions with distinctive symptom severity and course patterns as well as different age of onset profiles. The antecedent dysthymia is in its origin conceptualized as a "cluster" of intrapersonal and interactional symptoms (Shapiro 1975, Lewinsohn et al., 1978). Dysthymia usually begins with an insidious early onset before the age of 21 (Klein et al., 1996). Affected patients are unlikely to remit over time compared to pure MDD (McCullough, 1988, 1994). The course of the disorder is more frequent than not associated with a repetitious history of self-reported interpersonal disappointments or childhood trauma (Klein et al., 1996). In the context of Keller's and colleagues specificity research it was shown that the probability of both the dysthymia and the major depressive episode remitting following single treatment with either pharmacotherapy or psychotherapy is less than 40% (Keller, 1982, 1984, 1990, 1995; McCullough, 1996). Later studies demonstrated that the combination of psychotherapy and medication was proven to be more effective than medication alone (Keller et al., 1999). However, there are two major reasons that promote chronicity and early relapses of major depressive episodes that lie on the dysthymia side: (1) the interactional components of unmodified dysthymia with the ongoing environment's negative response predisposes the dysthmic patient to stuck in a repetitious state of learned helplessness, a condition that strongly prevents full remission with the consequence of higher relapse rates compared to pure MDD (Keller et al., 1982, 1984, 1988, 1990; McCullough et al., 1991, 1996); (2) the lifelong chronic course of untreated double depression places the individual at increased risk for poor general health and associated medical conditions like sleep disorders, anaemia, type-2 diabetes mellitus, hypothyroidism and substance abuse related disorders to name a few (McCullough et al., 1996; Moussavi et al., 2007; Trivedi et al., 2009). In late onset chronic unipolar depression the coincidence of dysthymia is the exception.

#### **1.2 The Sequenced Treatment Alternatives to Relieve Depression study**

The Sequenced Treatment Alternatives to Relieve Depression NIHM funded study (STAR\*D) was designed to determine which pharmacological treatments and augmentation strategies including cognitive therapy augmentation are most effective following nonremission or intolerance to an initial SSRI or to any of a series of subsequent randomised treatments (Rush et al., 2005). STAR\*D` represents the most important current "real world" treatment study ever done on MDD (Rush et al., 2005). Its population consisted of 4041 outpatients aged 18-75 years which were treated in 41 primary and specialty care settings

Chronic depression is defined as unipolar depressive disorder lasting two or more years with less than a two-month period during which the individual reports no symptoms. The rating for chronicity is contingent upon the density of symptoms at the time of assessment, every day in MDD and more days than not in dysthymia. Manic, mixed or hypomanic episodes are listed as exclusion criteria. Coincidences of symptoms with other psychiatric disorders frequently occur (American Psychiatric Association, 2000). In the DSM-IV mood disorders field trial seven chronic course descriptions were reliable differentiable (Klein, 1992; Keller et al., 1995; McCullough et al., 1996). The most common condition is represented by patients with early onset dysthymia that suffer the additional burden of either a more severe and pervasive major depressive episode or recurrent major depressive episodes with or without interepisode recovery (double depression), accounting for up to 75% of the total numbers of affected individuals (Klein et al., 1996). Double depression represents the simultaneous occurrence of two unipolar depressions with distinctive symptom severity and course patterns as well as different age of onset profiles. The antecedent dysthymia is in its origin conceptualized as a "cluster" of intrapersonal and interactional symptoms (Shapiro 1975, Lewinsohn et al., 1978). Dysthymia usually begins with an insidious early onset before the age of 21 (Klein et al., 1996). Affected patients are unlikely to remit over time compared to pure MDD (McCullough, 1988, 1994). The course of the disorder is more frequent than not associated with a repetitious history of self-reported interpersonal disappointments or childhood trauma (Klein et al., 1996). In the context of Keller's and colleagues specificity research it was shown that the probability of both the dysthymia and the major depressive episode remitting following single treatment with either pharmacotherapy or psychotherapy is less than 40% (Keller, 1982, 1984, 1990, 1995; McCullough, 1996). Later studies demonstrated that the combination of psychotherapy and medication was proven to be more effective than medication alone (Keller et al., 1999). However, there are two major reasons that promote chronicity and early relapses of major depressive episodes that lie on the dysthymia side: (1) the interactional components of unmodified dysthymia with the ongoing environment's negative response predisposes the dysthmic patient to stuck in a repetitious state of learned helplessness, a condition that strongly prevents full remission with the consequence of higher relapse rates compared to pure MDD (Keller et al., 1982, 1984, 1988, 1990; McCullough et al., 1991, 1996); (2) the lifelong chronic course of untreated double depression places the individual at increased risk for poor general health and associated medical conditions like sleep disorders, anaemia, type-2 diabetes mellitus, hypothyroidism and substance abuse related disorders to name a few (McCullough et al., 1996; Moussavi et al., 2007; Trivedi et al., 2009). In late onset chronic

unipolar depression the coincidence of dysthymia is the exception.

**1.2 The Sequenced Treatment Alternatives to Relieve Depression study**

The Sequenced Treatment Alternatives to Relieve Depression NIHM funded study (STAR\*D) was designed to determine which pharmacological treatments and augmentation strategies including cognitive therapy augmentation are most effective following nonremission or intolerance to an initial SSRI or to any of a series of subsequent randomised treatments (Rush et al., 2005). STAR\*D` represents the most important current "real world" treatment study ever done on MDD (Rush et al., 2005). Its population consisted of 4041 outpatients aged 18-75 years which were treated in 41 primary and specialty care settings

**1.1 Diagnostic issues of chronic MDD**

over a 37-month period. Outpatients with non-psychotic MDD with- and without antecedent dysthymia, and with other co-morbid mental and general medical conditions were included. The evaluable MDD population consisted of 2876 patients (72%) with a mean onset age of 25.3 years. The number of MD-episodes was 6, the length of the current MDepisode was 24.6 month, the length of illness was 15.5 years, and the number of concurrent medical conditions was 3.3. Cognitive therapy was available as either a switch from or augmentation of citalopram in the second step of treatment. Based on the first (n=3671), second (n=1439), third (n=390) and fourth (n=123) treatment steps, the corresponding remission rates were 36.8%, 30.6%, 13.7% and 13.0%, respectively, with an overall cumulative remission rate of 67%. In step-2 remission rates between cognitive therapy and medication in either the switch or augmentation strategies did not differ, although participants in cognitive therapy augmentation had a longer time to remission of 55 days compared to those in medication augmentation with 40 days. Treatment resistance was associated with more concurrent axis I or III co-morbid conditions, socioeconomic disadvantage, chronicity and melancholic or anxious features. With regard to longer-term outcomes a substantial number of patients relapsed. The cumulative proportion of participants without relapse during the naturalistic 12 month follow-up was highest in step 1 remitted patients compared to step 2 remitted patients. In comparison, those patients who were only partially remitted in step-1 and did not enter step-2 treatment had a 50% decreased survival rate compared to patients that remitted at step 1. In general, those patients who required more treatment steps had higher relapse rates during the naturalistic follow-up phase (Rush et. al 2006a, 2006b). The implications of STAR\* D are that at present there is a substantial lack of knowledge how to choose among and sequence the different available treatment strategies, how to deliver or implement these treatments, and how to identify which treatments will most benefit particular patients. It is also unknown, whether different strategies or tactics have better outcomes based on different treatment settings (Rush et al., 2009). Future treatment expectations suggest combined outcome criteria that target on complete syndromal remission and complete restoration of social functioning (Nelson et al., 2008). While the increase of the range of medications, biophysical interventions, comprehensive depression-targeted psychotherapies and somatic treatment is encouraging, effective treatment to achieve complete remission and, ultimately, long-term, successful outcomes of social functioning is an unsolved problem and remains an outstanding need in psychiatry, particularly in chronic MDD with antecedent dysthymia (McCullough et al., 1996; Kessler et al., 2003; Schoepf et al., 2007; Nelson et al., 2008).

#### **1.3 Cognitive Behavioral Analysis System of Psychotherapy (CBASP)**

In 2006, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) was officially introduced in Germany for the specific psychotherapeutic treatment of chronically depressed patients. CBASP is developed by James P McCullough Jr (USA) as a specific outpatient protocol that integrates interpersonal and cognitive-emotional strategies. McCullough started his clinical carrier as a "first-wave" operant behavior therapist in the early 70th of the last decade. His work is deeply influenced by Skinner's tradition of radical behaviorism. CBASP addresses directly the specific intrapersonal and interpersonal symptoms of MDD with antecedent dysthymia (double depression). From a perspective of behavior therapy, behavior theory approaches from original and revised models of behavior therapy are incorporated with a strong disengage from the pure cognitive content focus of cognitive therapy. In addition, CBASP uses elements of "third wave" of cognitive behavior therapy methods that

Cognitive Behavioral Analysis System of Psychotherapy (CBASP):

et al., 2010a).

**2. First part**

**1.4 Aim of chapter**

depressive episodes (Schoepf et al., 2008b).

A Disorder-Oriented, Theory-Driven Psychotherapy Method from the "Third Generation"… 91

diagnosed with chronic depression and PTSD. The outcome criteria focus on the reduction in symptoms of avoidance and hyper-arousal present in both, as well as the reduction in depressive symptoms (Favorite, 2010). A further US research line represents the use of CBASP for treating chronically depressed alcoholics in an integrated treatment approach that focuses on simultaneous reductions of depressive symptoms and alcohol intake (Penberthy, 2010). In addition, by the research on the neural mechanisms of chronic depression and the impact of CBASP on behavioural and neural functioning (Schnell et al., 2010), more is learned about the fundamental processes of learning and memory that take place during administering CBASP intervention strategies (Walter et al., 2009; McCullough

In the first part important information is summarized about the influence of adaptation on functioning on a formal operational level (Schoepf et al., 2007), learning mechanisms (Schoepf et al., 2007; Neudeck et al., 2010), passive and active ways of stimulus recognition (Schoepf et al., 2007; Neudeck et al., 2010), aetiology and characteristics of double depression (Schoepf et al., 2007; Schoepf et al., 2008a, 2009a, 2009b; Schoepf and Penberthy, 2010), the therapist's function as a reinforcer within the therapeutic relationship (Schoepf et al., 2008b), CBASP`s cutting edges of behaviour change and the principles of intervention, therapeutic goals (Schoepf and McCullough, 2009b), and the treatment strategies and there corresponding mechanisms of action subdivided into "bottom-up" and "top-down" interventions (Schoepf et al., 2007, 2008a). In the second part a multi-step psychotherapy approach is represented that integrates CBASP`s intervention strategies in the therapy of chronic MDD German patients with an inpatient history of therapy-refractory major

**2.1 The influence of childhood adaptation on functioning on a formal operational level**  Evolution is defined as a process that allows adaptation between generations. In contrast the term learning is defined as a process that allows environmental adaptation within an organism's lifetime. As organisms behave as if evolution has "prepared" them to associate certain events learning has to be viewed always within its evolutionary context (Bouton, 2007). According to Piaget`s systems-theoretical biological theory, every new organized element of reaction and experience is learned on the stimulus-response level. The application of the element automatically happens in the daily living arena outside the original learning situation (functional and generalizing assimilation). The interaction of accommodation and assimilation creates a dynamic balance on the respective higher cognitive-emotional level as compared to the "specific regulatory factor underlying a biological organization", which he calls adaptation (Piaget, 1973). Successful adaptation leads to the capacity of functioning on a formal operational level with growth of self-efficacy through transitional experiences in the formative period of adolescence. In the crucial period of adolescence the roles of adulthood have to be addressed in almost every dimension of life. A formal operational adolescent is connected to its informing environment and is attached to others, is affected by and changed by the behavior consequences he receives from other interactants. In addition, he is able to recognize the consequences of his behaviors and may develop problem-solving skills, may develop foresight in planning, may develop future orientation, and may have the capacity to directly

deal with models of self-regulation with respect to motivational and cognitive factors in metacognitive processing (Teasdale, 1999) as well as concepts of modern learning theory (Bouton, 2007; McCullough et al., 2010a; McCullough, 2010c). It is important to note that CBASP requires the therapist's personal involvement (McCullough, 2006). Based on Bandura's early behavioral paradigm that psychological functioning involves a reciprocal interaction between behavior and its controlling environment (Bandura, 1969), the CBASP-therapist is viewed as the primary choreographer of behavior change. The therapist, beginning in the first session of therapy, deliberately constructs a qualitatively different interpersonal environment for the individual as well as enacts a disciplined personal involvement role that stands in contrast to the relationships the early-onset chronically depressed patient has experienced with his "Significant Others" (McCullough et al., 2010b). CBASP primarily focuses on the in-session learning process of the patient. In agreement, McCullough's model has been developed through a process of trial and error and over the course of many therapy sessions with various patients into an in-session acquisition learning model (McCullough, 2006). Two types of dependent variables are being distinguished that model the specific learning success, the therapy process and the reduction of symptoms. The first type refers to the learning success and the learning process, i.e., the patient's ability to notice the consequences of his behavior, the patient's ability to apply the "Situational Analysis" independently, the reduction of destructive interpersonal behavior and the patient's ability to confidently draw an emotional distinction between the therapist and his or her "Significant Others". The second type refers to symptom-specific treatment effects, i.e., the reduction of the quality of depression with respect to self perception and the perception of others, the reduction of psycho-social impairment, higher quality of the marital relationship and other factors (McCullough, 2006).

#### **1.3.1 Efficacy of the CBASP and its most important newer applications**

CBASP has demonstrated significant effects for treating refractory outpatients with chronic MDD (Keller et al., 2000; Nemeroff et al., 2003; Schramm et al. 2010a), especially in its combination with medication (Keller et al., 2000), developmental trauma (Nemeroff et al., 2003), and double depression (Schramm et al. 2010a). In contrast, in the recently published REVAMP trial (Kocsis et al., 2009) CBASP augmentation with administering of 12.5 hours of psychotherapy (over the intention-to-treat study population) in partially remitted patients with chronic MDD (who had a preference for pharmacotherapy), CBASP was found not to be more effective in reduction of acute symptoms than pharmacological augmentation or augmentation with supportive therapy**.** However, CBASP (with introducing the technique of "Situational Analysis" in the third session) plus pharmacotherapy was associated with significantly greater improvement in problem solving than Brief Supportive Psychotherapy plus pharmacotherapy; or medication alone (Klein et al., 2011). The implications are (1) that at present it is not clear what treatment dosage level works the best for the CBASP and (2) under which treatment circumstances CBASP is most effective (Schramm et al., 2010b). In addition, it is not clear if the US protocol that introduces the technique of "Situational Analysis" in the third session of therapy has a positive or negative impact on in-session acquisition learning and outcome-measures (Schoepf et al., 2011). A pilot study of a multidisciplinary structured three month German inpatient CBASP program shows promising findings on short- and long-term outcomes as well as on feasibility (Brakemeier et al., 2011). New applications of CBASP represent CBASP in group format in Germany, Canada, and the USA. In Canada, a manual for group CBASP in an inpatient setting that focuses on improvements in perceived functionality shows promising preliminary results (Sayegh, 2010). An ongoing study in the US explores the use of group CBASP with veterans diagnosed with chronic depression and PTSD. The outcome criteria focus on the reduction in symptoms of avoidance and hyper-arousal present in both, as well as the reduction in depressive symptoms (Favorite, 2010). A further US research line represents the use of CBASP for treating chronically depressed alcoholics in an integrated treatment approach that focuses on simultaneous reductions of depressive symptoms and alcohol intake (Penberthy, 2010). In addition, by the research on the neural mechanisms of chronic depression and the impact of CBASP on behavioural and neural functioning (Schnell et al., 2010), more is learned about the fundamental processes of learning and memory that take place during administering CBASP intervention strategies (Walter et al., 2009; McCullough et al., 2010a).

#### **1.4 Aim of chapter**

90 Psychiatric Disorders – Worldwide Advances

deal with models of self-regulation with respect to motivational and cognitive factors in metacognitive processing (Teasdale, 1999) as well as concepts of modern learning theory (Bouton, 2007; McCullough et al., 2010a; McCullough, 2010c). It is important to note that CBASP requires the therapist's personal involvement (McCullough, 2006). Based on Bandura's early behavioral paradigm that psychological functioning involves a reciprocal interaction between behavior and its controlling environment (Bandura, 1969), the CBASP-therapist is viewed as the primary choreographer of behavior change. The therapist, beginning in the first session of therapy, deliberately constructs a qualitatively different interpersonal environment for the individual as well as enacts a disciplined personal involvement role that stands in contrast to the relationships the early-onset chronically depressed patient has experienced with his "Significant Others" (McCullough et al., 2010b). CBASP primarily focuses on the in-session learning process of the patient. In agreement, McCullough's model has been developed through a process of trial and error and over the course of many therapy sessions with various patients into an in-session acquisition learning model (McCullough, 2006). Two types of dependent variables are being distinguished that model the specific learning success, the therapy process and the reduction of symptoms. The first type refers to the learning success and the learning process, i.e., the patient's ability to notice the consequences of his behavior, the patient's ability to apply the "Situational Analysis" independently, the reduction of destructive interpersonal behavior and the patient's ability to confidently draw an emotional distinction between the therapist and his or her "Significant Others". The second type refers to symptom-specific treatment effects, i.e., the reduction of the quality of depression with respect to self perception and the perception of others, the reduction of psycho-social impairment,

higher quality of the marital relationship and other factors (McCullough, 2006).

**1.3.1 Efficacy of the CBASP and its most important newer applications**

CBASP has demonstrated significant effects for treating refractory outpatients with chronic MDD (Keller et al., 2000; Nemeroff et al., 2003; Schramm et al. 2010a), especially in its combination with medication (Keller et al., 2000), developmental trauma (Nemeroff et al., 2003), and double depression (Schramm et al. 2010a). In contrast, in the recently published REVAMP trial (Kocsis et al., 2009) CBASP augmentation with administering of 12.5 hours of psychotherapy (over the intention-to-treat study population) in partially remitted patients with chronic MDD (who had a preference for pharmacotherapy), CBASP was found not to be more effective in reduction of acute symptoms than pharmacological augmentation or augmentation with supportive therapy**.** However, CBASP (with introducing the technique of "Situational Analysis" in the third session) plus pharmacotherapy was associated with significantly greater improvement in problem solving than Brief Supportive Psychotherapy plus pharmacotherapy; or medication alone (Klein et al., 2011). The implications are (1) that at present it is not clear what treatment dosage level works the best for the CBASP and (2) under which treatment circumstances CBASP is most effective (Schramm et al., 2010b). In addition, it is not clear if the US protocol that introduces the technique of "Situational Analysis" in the third session of therapy has a positive or negative impact on in-session acquisition learning and outcome-measures (Schoepf et al., 2011). A pilot study of a multidisciplinary structured three month German inpatient CBASP program shows promising findings on short- and long-term outcomes as well as on feasibility (Brakemeier et al., 2011). New applications of CBASP represent CBASP in group format in Germany, Canada, and the USA. In Canada, a manual for group CBASP in an inpatient setting that focuses on improvements in perceived functionality shows promising preliminary results (Sayegh, 2010). An ongoing study in the US explores the use of group CBASP with veterans In the first part important information is summarized about the influence of adaptation on functioning on a formal operational level (Schoepf et al., 2007), learning mechanisms (Schoepf et al., 2007; Neudeck et al., 2010), passive and active ways of stimulus recognition (Schoepf et al., 2007; Neudeck et al., 2010), aetiology and characteristics of double depression (Schoepf et al., 2007; Schoepf et al., 2008a, 2009a, 2009b; Schoepf and Penberthy, 2010), the therapist's function as a reinforcer within the therapeutic relationship (Schoepf et al., 2008b), CBASP`s cutting edges of behaviour change and the principles of intervention, therapeutic goals (Schoepf and McCullough, 2009b), and the treatment strategies and there corresponding mechanisms of action subdivided into "bottom-up" and "top-down" interventions (Schoepf et al., 2007, 2008a). In the second part a multi-step psychotherapy approach is represented that integrates CBASP`s intervention strategies in the therapy of chronic MDD German patients with an inpatient history of therapy-refractory major depressive episodes (Schoepf et al., 2008b).

#### **2. First part**

**2.1 The influence of childhood adaptation on functioning on a formal operational level**  Evolution is defined as a process that allows adaptation between generations. In contrast the term learning is defined as a process that allows environmental adaptation within an organism's lifetime. As organisms behave as if evolution has "prepared" them to associate certain events learning has to be viewed always within its evolutionary context (Bouton, 2007). According to Piaget`s systems-theoretical biological theory, every new organized element of reaction and experience is learned on the stimulus-response level. The application of the element automatically happens in the daily living arena outside the original learning situation (functional and generalizing assimilation). The interaction of accommodation and assimilation creates a dynamic balance on the respective higher cognitive-emotional level as compared to the "specific regulatory factor underlying a biological organization", which he calls adaptation (Piaget, 1973). Successful adaptation leads to the capacity of functioning on a formal operational level with growth of self-efficacy through transitional experiences in the formative period of adolescence. In the crucial period of adolescence the roles of adulthood have to be addressed in almost every dimension of life. A formal operational adolescent is connected to its informing environment and is attached to others, is affected by and changed by the behavior consequences he receives from other interactants. In addition, he is able to recognize the consequences of his behaviors and may develop problem-solving skills, may develop foresight in planning, may develop future orientation, and may have the capacity to directly

Cognitive Behavioral Analysis System of Psychotherapy (CBASP):

that predicts an aversive event causes loss of motivation or anxiety.

**2.1.2 Associative learning of behavioural effects**

encounters a predator.

(unconscious level),

"aversive/negative" outcomes.

(unconscious and conscious level),

(unconscious and conscious level).

action:

A Disorder-Oriented, Theory-Driven Psychotherapy Method from the "Third Generation"… 93

stimuli that have never been directly associated with an unconditioned stimulus can elicit conditioned responses. Furthermore, the information value of a "biologically" important event is associated with the child's motivational state. The anticipation of a conditioned stimulus that predicts a "good" event causes motivation whereas the anticipation of a conditioned stimulus

Associative learning of signalling stimuli may cause implicit shifts of attention in humans. Animal findings show that approaching tendencies towards "good" events and withdrawing tendencies away from "aversive" events are strongly associated with shifts of attention. This general tendency is known as positive and negative sign tracking. Sign tracking is assumed to trigger whole sets of behaviour systems and physiological reactions that may help to ensure that animals continue to make contact with "safe events" and to stay away from "dangerous events". In case that a conditioned stimulus predicts danger either species-specific defence reaction behaviour systems are elicited or more general avoidance reactions can be triggered that aren't species-specific. Species-specific defence reactions describe innate reactions like freezing and fleeing that occur when an organism

In contrast, children learn to increase or decrease their contact with "biologically" significant events through instrumental learning. Behaviours that are controlled by there consequences represent instrumentally conditioned behaviours. Instrumental action is always guided by associative learning of signalling stimuli. Four associations are learned in instrumental

associations between signalling-stimuli of the environment and reflexive behaviours

associations between signalling stimuli of the environment and behavioural tendencies

and associations between discriminative (contextual) stimuli and behaviours

When instrumental action is controlled by the discriminative stimulus that precedes it the learning mechanism is called stimulus control. Through stimulus control the child learns to discriminate events in which behaviour is reinforced from events were behaviour is not. So called occasion setters simply involve "context cues" that are always present whenever instrumental learning occurs; occasion setters mark the spot where/when the child associates that some behaviour will deliver a reinforcer (discriminative stimulus in Skinnerian language). Reinforcement means strengthening of a specific learning mechanism. Positive reinforcement is defined as a specific situation in which behaviour is followed by a "good" event that represents a positive reinforcer. Negative reinforcement is defined as a specific situation in which behaviour is strengthened because it removes or prevents an aversive event that is a negative reinforcer. Figure two represents the possible relations between behavioural effects and "biologically" significant events in instrumental learning. Instrumental action may cause implicit shifts of reward and punishment expectations in humans that may help the individual to increase the contact with events that are expected to have "good" outcomes, and to decrease the contact with events that are expected to have

associations between behaviours and there perceived effects (conscious level),

confront fearful encounters. Childhood conditions that are likely to produce the development of formal operational thought in the period of adolescence are close relationships with competent and caring adults in the family, the capacity to develop self-regulation abilities, a positive view of self, cognitive motivation to be effective in the environment (i.e., self efficacy and self-determination), friendships, and romantic attachments with pro-social peers (Masten, 2007).

#### **2.1.1 Associative learning of signalling stimuli**

A child is biologically prepared to learn to associate signalling stimuli of the environment (cues or incentives) with stimuli that elicit respondent behaviours through the mechanism of classical conditioning. Figure 1 demonstrates the possible relations between signalling stimuli and behavioural tendencies in signal learning.

Fig. 1. Associative learning of signalling stimuli. The prediction of a "biologically" important event [E\*] causes either approaching tendencies or withdrawing tendencies. S = conditioned stimulus that predicts the presence or absence of E\*. Left upper cell: when a signal predicts a good E\* animals often begin to approach the signal (positive sign tracking). Right upper cell: when a signal predicts an aversive E\* animals tend to withdraw from the signal (negative sign tracking). Left lower cell*:* when a signal predicts a decrease in the probability of a good E\* animals withdraw from it. Right lower cell: when a signal predicts a decrease in the probability of an aversive E\* animals tend to approach it (modified according to Bouton, 2007; Schoepf et al., 2007).

Classical conditioning is sensitive to the timing, intensity, and to the novelty of "biological" important events. After classical conditioning has happened a former neutral stimulus elicits a conditional response (interceptive, emotional, and behavioural) that allows the child to prepare as early as possible for the upcoming event as a behavioural phenomenon (signalling stimuli in Pavlovian language). In addition, second- and higher order conditioning, stimulus independent sensory preconditioning, and generalization each provide further ways in which stimuli that have never been directly associated with an unconditioned stimulus can elicit conditioned responses. Furthermore, the information value of a "biologically" important event is associated with the child's motivational state. The anticipation of a conditioned stimulus that predicts a "good" event causes motivation whereas the anticipation of a conditioned stimulus that predicts an aversive event causes loss of motivation or anxiety.

Associative learning of signalling stimuli may cause implicit shifts of attention in humans. Animal findings show that approaching tendencies towards "good" events and withdrawing tendencies away from "aversive" events are strongly associated with shifts of attention. This general tendency is known as positive and negative sign tracking. Sign tracking is assumed to trigger whole sets of behaviour systems and physiological reactions that may help to ensure that animals continue to make contact with "safe events" and to stay away from "dangerous events". In case that a conditioned stimulus predicts danger either species-specific defence reaction behaviour systems are elicited or more general avoidance reactions can be triggered that aren't species-specific. Species-specific defence reactions describe innate reactions like freezing and fleeing that occur when an organism encounters a predator.

#### **2.1.2 Associative learning of behavioural effects**

92 Psychiatric Disorders – Worldwide Advances

confront fearful encounters. Childhood conditions that are likely to produce the development of formal operational thought in the period of adolescence are close relationships with competent and caring adults in the family, the capacity to develop self-regulation abilities, a positive view of self, cognitive motivation to be effective in the environment (i.e., self efficacy and self-determination), friendships, and romantic attachments with pro-social peers (Masten,

A child is biologically prepared to learn to associate signalling stimuli of the environment (cues or incentives) with stimuli that elicit respondent behaviours through the mechanism of classical conditioning. Figure 1 demonstrates the possible relations between signalling

**Approach**

Fig. 1. Associative learning of signalling stimuli. The prediction of a "biologically"

decrease in the probability of an aversive E\* animals tend to approach it (modified

important event [E\*] causes either approaching tendencies or withdrawing tendencies. S = conditioned stimulus that predicts the presence or absence of E\*. Left upper cell: when a signal predicts a good E\* animals often begin to approach the signal (positive sign tracking). Right upper cell: when a signal predicts an aversive E\* animals tend to withdraw from the signal (negative sign tracking). Left lower cell*:* when a signal predicts a decrease in the probability of a good E\* animals withdraw from it. Right lower cell: when a signal predicts a

Classical conditioning is sensitive to the timing, intensity, and to the novelty of "biological" important events. After classical conditioning has happened a former neutral stimulus elicits a conditional response (interceptive, emotional, and behavioural) that allows the child to prepare as early as possible for the upcoming event as a behavioural phenomenon (signalling stimuli in Pavlovian language). In addition, second- and higher order conditioning, stimulus independent sensory preconditioning, and generalization each provide further ways in which

**Good E\* Aversive E\***

**Withdraw**

**Withdraw Approach**

2007).

**Figure 1**

**SIGNAL LEARNING**

**R predicts absence of E\***

according to Bouton, 2007; Schoepf et al., 2007).

**R predicts E\***

**2.1.1 Associative learning of signalling stimuli**

stimuli and behavioural tendencies in signal learning.

In contrast, children learn to increase or decrease their contact with "biologically" significant events through instrumental learning. Behaviours that are controlled by there consequences represent instrumentally conditioned behaviours. Instrumental action is always guided by associative learning of signalling stimuli. Four associations are learned in instrumental action:

When instrumental action is controlled by the discriminative stimulus that precedes it the learning mechanism is called stimulus control. Through stimulus control the child learns to discriminate events in which behaviour is reinforced from events were behaviour is not. So called occasion setters simply involve "context cues" that are always present whenever instrumental learning occurs; occasion setters mark the spot where/when the child associates that some behaviour will deliver a reinforcer (discriminative stimulus in Skinnerian language). Reinforcement means strengthening of a specific learning mechanism. Positive reinforcement is defined as a specific situation in which behaviour is followed by a "good" event that represents a positive reinforcer. Negative reinforcement is defined as a specific situation in which behaviour is strengthened because it removes or prevents an aversive event that is a negative reinforcer. Figure two represents the possible relations between behavioural effects and "biologically" significant events in instrumental learning.

Instrumental action may cause implicit shifts of reward and punishment expectations in humans that may help the individual to increase the contact with events that are expected to have "good" outcomes, and to decrease the contact with events that are expected to have "aversive/negative" outcomes.

Cognitive Behavioral Analysis System of Psychotherapy (CBASP):

**2.1.4 Passive and active ways of stimulus recognition**

recognition exist: bottom-up and top-down.

al., 2007; Neudeck et al., 2010).

four contributing factors:

A Disorder-Oriented, Theory-Driven Psychotherapy Method from the "Third Generation"… 95

Associative learning of signalling stimuli and instrumental action are present in all learning situations because of the simple cognitive association of what-leads-to-what. The conditioned stimulus represents the "stimulus signal" that runs the situational outcome. In other words, learning on a formal-operative level of functioning is cognitively associating what signal is connected to what upcoming event and how to keep the event coming or removing. Therefore perception and behavior are closely coupled. Perception is defined as the processing of information that is acquired through one of the senses (sight, hearing, smell, taste, touch). This information about the structure of the physical world is used for the adaptive control of behavior. Two different types of processes or ways of stimulus

 In the case of "bottom-up processing," a specific property of the stimulus is detected; the specific stimulus properties are then combined into more complex forms until final stimulus recognition takes place. This explains why bottom-up processing is sometimes referred to as "passive" (perception). Anatomical correlates to bottom-up processes

 By contrast, in "top-down processing," hypotheses about the stimulus as a whole are formed (expectations and prior knowledge); then specific properties are selected and tested and, finally, stimulus recognition occurs. Top-down processing is referred to as "active" (behavior). Top-down processes (given sufficient sensorial stimulation or individually developed goals) can be represented in the dorsolateral or the prefrontal regions as well as the anterior cingulate gyrus and the basal cerebral cortex (Schoepf et

Chronic MDD with antecedent dysthymia (double depression) usually begins around 13-14 years of age. McCullough holds that the psychopathology of chronically depressed patients results, to a large degree, from bidirectional interaction between disturbed emotion and stress regulation on the one hand and developmentally inhibiting "person-environment" conditions on the other hand, i.e. in situations where the individual was subject to repetitive experiences of helplessness. The attachment disorder (with a negative attributional style and disturbed behaviours) is perpetuated through generalized avoidance learning, thus accounting for an uncoupling of the person-environment connection (Schoepf et al., 2007, 2008a). It is important to note, that the disorder is as well caused as maintained by global deficits in cognitive-emotional development that involve intrapersonal and interactional domains. The psychological organization is similar to the organization of children during their preoperational stage of development (Schoepf et al., 2008a, 2008b, 2009a). According to a reciprocal model of causation, the decreased cognitive-emotional development results of

the genetic contributor represents genetically caused dispositions and personality

 the environmental contributor represents early experiences of loss and/or chronic neglect in combination with later adverse life events in the form of failures, hardships,

 the cognitive contributor and the behavioral contributor both represent the intrapersonal and interactional effects of recurrent experiences of helplessness when

include the brain stem and the basal forebrain (affect-driven attention).

**2.2 Aetiological background and characteristics of double depression**

factors like internalizing or externalizing negative affect,

and lack or loss of emotional relationships,

Fig. 2. The law of effect in instrumental action. The effects of behaviours [R] determine the type of learning. Left upper cell: reward learning causes an increase of a behaviour if the behaviour produces a "good" event [E\*]. Right upper cell: if behaviour is followed by an aversive E\* (punishment) the behaviour typically decreases in strength. Left lower cell: behaviour decreases in strength if it prevents a "good" E\* (omission). Right lower cell: if a specific behaviour prevents an aversive E\* avoidance or escape learning happens (modified according to Bouton, 2007; Schoepf et al., 2007).

#### **2.1.3 Non-associative learning mechanisms**

In contrast, sensitization and habituation represent two forms of non-associative learning since, in order for a response to occur, no association or combination of stimuli is necessary. Both mechanisms are stored as knowledge in the part of the memory system that is called implicit (non-declarative) memory. It is where behavior, skills, and priming processes are stored. Both mechanisms are triggered by a specific cognitive stimulus processing and they originate in certain plastic processes in the nervous system. Sensitization is defined as enhanced perception and increased responsiveness (response readiness) when repeatedly confronted with a certain sensory stimulus. Sensitization represents a mechanism of the central nervous system that plays an important physiological role in everyday life. As a result of the repeated presentation of a specific stimulus, an increase in response occurs. Sensitization therefore represents an induction procedure (caused by specific stimulus properties) and the resulting measurable responsivity. If the induction procedure causes an appropriate response, its perpetual repetition leads to a specific learning process that causes hyper-responsivity. A typical increase in response is an increase of attention with respect to the stimulus cue. Through sensitization, we learn to pay special attention to important stimuli, rather than ignoring them. Sensitization is largely unspecific to the stimulus, which makes it different from habituation. The better known mechanism of habituation describes the opposite, meaning a decrease in response to a stimulus that is repeatedly presented (Neudeck et al., 2010).

#### **2.1.4 Passive and active ways of stimulus recognition**

94 Psychiatric Disorders – Worldwide Advances

**Reward**

Fig. 2. The law of effect in instrumental action. The effects of behaviours [R] determine the type of learning. Left upper cell: reward learning causes an increase of a behaviour if the behaviour produces a "good" event [E\*]. Right upper cell: if behaviour is followed by an aversive E\* (punishment) the behaviour typically decreases in strength. Left lower cell: behaviour decreases in strength if it prevents a "good" E\* (omission). Right lower cell: if a specific behaviour prevents an aversive E\* avoidance or escape learning happens (modified

In contrast, sensitization and habituation represent two forms of non-associative learning since, in order for a response to occur, no association or combination of stimuli is necessary. Both mechanisms are stored as knowledge in the part of the memory system that is called implicit (non-declarative) memory. It is where behavior, skills, and priming processes are stored. Both mechanisms are triggered by a specific cognitive stimulus processing and they originate in certain plastic processes in the nervous system. Sensitization is defined as enhanced perception and increased responsiveness (response readiness) when repeatedly confronted with a certain sensory stimulus. Sensitization represents a mechanism of the central nervous system that plays an important physiological role in everyday life. As a result of the repeated presentation of a specific stimulus, an increase in response occurs. Sensitization therefore represents an induction procedure (caused by specific stimulus properties) and the resulting measurable responsivity. If the induction procedure causes an appropriate response, its perpetual repetition leads to a specific learning process that causes hyper-responsivity. A typical increase in response is an increase of attention with respect to the stimulus cue. Through sensitization, we learn to pay special attention to important stimuli, rather than ignoring them. Sensitization is largely unspecific to the stimulus, which makes it different from habituation. The better known mechanism of habituation describes the opposite, meaning a decrease in response to a stimulus that is repeatedly presented

**Good E\* Aversive E\***

**Punish**

**Omission Avoidance**

**Figure 2**

**INSTRUMENTAL LEARNING**

**R prevents E\***

according to Bouton, 2007; Schoepf et al., 2007).

**2.1.3 Non-associative learning mechanisms**

(Neudeck et al., 2010).

**R produces E\***

Associative learning of signalling stimuli and instrumental action are present in all learning situations because of the simple cognitive association of what-leads-to-what. The conditioned stimulus represents the "stimulus signal" that runs the situational outcome. In other words, learning on a formal-operative level of functioning is cognitively associating what signal is connected to what upcoming event and how to keep the event coming or removing. Therefore perception and behavior are closely coupled. Perception is defined as the processing of information that is acquired through one of the senses (sight, hearing, smell, taste, touch). This information about the structure of the physical world is used for the adaptive control of behavior. Two different types of processes or ways of stimulus recognition exist: bottom-up and top-down.

#### **2.2 Aetiological background and characteristics of double depression**

Chronic MDD with antecedent dysthymia (double depression) usually begins around 13-14 years of age. McCullough holds that the psychopathology of chronically depressed patients results, to a large degree, from bidirectional interaction between disturbed emotion and stress regulation on the one hand and developmentally inhibiting "person-environment" conditions on the other hand, i.e. in situations where the individual was subject to repetitive experiences of helplessness. The attachment disorder (with a negative attributional style and disturbed behaviours) is perpetuated through generalized avoidance learning, thus accounting for an uncoupling of the person-environment connection (Schoepf et al., 2007, 2008a). It is important to note, that the disorder is as well caused as maintained by global deficits in cognitive-emotional development that involve intrapersonal and interactional domains. The psychological organization is similar to the organization of children during their preoperational stage of development (Schoepf et al., 2008a, 2008b, 2009a). According to a reciprocal model of causation, the decreased cognitive-emotional development results of four contributing factors:

Cognitive Behavioral Analysis System of Psychotherapy (CBASP):

conceptualisation of learned helplessness:

 emotional deregulations, survival behaviour.

as submissively as I can"

other different way than submissive"

strong responses of punishment and rejection"

environment can not inform the patient (McCullough, 2007).

generalized negative outcome expectancies,

negative cognized goals.

**The attentional system is biased towards unexpected events**

stimulus that predicts uncontrollability or unpredictability

 a severely decreased cognitive-learning ability, a significantly decreased motivation to cope problems,

**<IP_ADDRESS> Intrapersonal destructiveness of the learned helplessness effect**

severely disturbed female patient with double depression prior to treatment.

A Disorder-Oriented, Theory-Driven Psychotherapy Method from the "Third Generation"… 97

Table one represents the intrapersonal characteristics of the learned helplessness effect in a

The intrapersonal destructiveness of the learned helplessness effect is cognitive-emotional stunting when the child's world becomes so aversive or uncontrollable that mastery of interactional problems is experienced as impossible. The pre-causal and pre-logical child cannot solve the destructive onslaught of its environment and is thrust into an "emotional survival" mode of living. Three negative cognitive effects are implicit within the

**The destructiveness of the leaned helplessness effect is characterised by**

**The reward system is biased towards the expectation of punishment**

**First expectation:** "less punishment/rejection results from the environment if I react

**Second expectation:** "punishment results from the environment if I react in any

The release of social fear is elicited by fast detection of any verbal- or nonverbal

Table 1. Double depression of the adult is usually associated with a refractory cognitiveemotional dilemma. What is observed at the beginning of treatment is an interpersonally avoidant patient with predomination of detached, distant and submissive behaviour. Instrumental avoidance of interpersonal encounter that holds the avoidance of the classical

conditioned fear in abeyance is the predominant strategy. As a consequence the

generalized retrospective negative causal attributions of failure and success,

The intrapersonal effects become aware to the child at the point when the child is able to conclude that it doesn't matter what it does with a resulting independent of response expectation. From this time on the child is a prison holder of an ongoing "emotional survival" mode that is strongly coupled with a poor cognitive regulation of motivation. As a consequence the child is (in more cases than not) not able to develop a formal-operative mode of cognitive-emotional functioning in later developmental phases, cognitive-

 **Instrumentally learned rule:** "I have to behave totally passively and submissively with the consequence of being shoved around. If I react actively - independently of the way I express my needs (independent of my stimulus value) - I will experience

interacting with the "Significant Others" during childhood (Schoepf et al., 2007, 2008a, 2008b, 2009a; Schoepf and Penberthy, 2010).

#### **2.2.1 Cognitive-emotional level of organization and core pathology**

The cognitive-emotional level of organization of the early-onset chronically depressed patient is characterized by preoperational representations in connection with a preoperational thinking style and wishful thinking. This explains why, instead of thinking in an action-oriented and goal-oriented manner, there are deficits in the areas of logical thinking, concept formation, problem solving and reasoning. In addition, affectivity has a powerful impact, causing overwhelming emotions that seem uncontrollable from the patient's subjective point of view. Patients are unable to identify what causes these alterations as their thoughts are constantly revolving around themselves. As a result, the patient does not receive information from his or her environment in an adequate way and is therefore not adequately influenced by relevant environmental incentives

The core pathology is contingent on the disturbed person-environment interaction. The chronically depressed patient experiences the world in dysfunctional ways across different situations and exhibits strikingly maladjusted social behavior. Typical dysfunctional ways of interpreting a situation include: "none will ever be able to forgive me," "it would be best to just die," "I'm a total failure," "I regularly escape into my fantasy world," "whatever I do ends up being wrong," and "everything is always my fault." Social interaction is replaced by interpersonal avoidance behavior in asymmetrical and inflexible ways. Patients typically show hostile-dominant and hostilesubmissive personality dimensions. In addition, a chronically low self-esteem value is found as well as feelings of hopelessness that generalize over all interpersonal situations. There are also problems with memory and recalling, poor abilities to observe accurately, diminished self-perception and insufficient processing of new experiences. Due to the weight that McCullough's multidimensional approach puts on the disturbed person-environment-relationship and the resulting deficient ability to act, the patient's core pathology, i.e., the maladjusted way of experiencing the world and the maladjustment with respect to social interaction, becomes the major focus of therapy. McCullough states "I have developed the CBASP to penetrate and change closed perceptual systems of early-onset chronically depressed patients that are closely related to the developmental influence of recurrent experiences of helplessness" (McCullough, 2006; McCullough, 2008; Schoepf et al., 2009a).

#### **2.2.2 The influence of recurrent experiences of helplessness in childhood and adolescence**

In general, recurrent (daily) experiences of helplessness have catastrophically psychological ramifications, particularly during childhood development. Seligman's theory of learned helplessness claims in its origin that noncontingent environmental reinforcement responses to a person's behavior reduces the incentive motivation to control the outcome of an event, interferes with further event related outcome learning, and if the outcome is traumatically processed, produces fear as long as the subject is uncertain of the uncontrollability of the outcome, and then produces the state of helplessness and hopelessness (Seligman, 1975; Abramson et al., 1978).

#### **<IP_ADDRESS> Intrapersonal destructiveness of the learned helplessness effect**

Table one represents the intrapersonal characteristics of the learned helplessness effect in a severely disturbed female patient with double depression prior to treatment.

The intrapersonal destructiveness of the learned helplessness effect is cognitive-emotional stunting when the child's world becomes so aversive or uncontrollable that mastery of interactional problems is experienced as impossible. The pre-causal and pre-logical child cannot solve the destructive onslaught of its environment and is thrust into an "emotional survival" mode of living. Three negative cognitive effects are implicit within the conceptualisation of learned helplessness:

#### **The destructiveness of the leaned helplessness effect is characterised by**

96 Psychiatric Disorders – Worldwide Advances

The cognitive-emotional level of organization of the early-onset chronically depressed patient is characterized by preoperational representations in connection with a preoperational thinking style and wishful thinking. This explains why, instead of thinking in an action-oriented and goal-oriented manner, there are deficits in the areas of logical thinking, concept formation, problem solving and reasoning. In addition, affectivity has a powerful impact, causing overwhelming emotions that seem uncontrollable from the patient's subjective point of view. Patients are unable to identify what causes these alterations as their thoughts are constantly revolving around themselves. As a result, the patient does not receive information from his or her environment in an adequate way and is

The core pathology is contingent on the disturbed person-environment interaction. The chronically depressed patient experiences the world in dysfunctional ways across different situations and exhibits strikingly maladjusted social behavior. Typical dysfunctional ways of interpreting a situation include: "none will ever be able to forgive me," "it would be best to just die," "I'm a total failure," "I regularly escape into my fantasy world," "whatever I do ends up being wrong," and "everything is always my fault." Social interaction is replaced by interpersonal avoidance behavior in asymmetrical and inflexible ways. Patients typically show hostile-dominant and hostilesubmissive personality dimensions. In addition, a chronically low self-esteem value is found as well as feelings of hopelessness that generalize over all interpersonal situations. There are also problems with memory and recalling, poor abilities to observe accurately, diminished self-perception and insufficient processing of new experiences. Due to the weight that McCullough's multidimensional approach puts on the disturbed person-environment-relationship and the resulting deficient ability to act, the patient's core pathology, i.e., the maladjusted way of experiencing the world and the maladjustment with respect to social interaction, becomes the major focus of therapy. McCullough states "I have developed the CBASP to penetrate and change closed perceptual systems of early-onset chronically depressed patients that are closely related to the developmental influence of recurrent experiences of helplessness" (McCullough,

**2.2.2 The influence of recurrent experiences of helplessness in childhood and**

In general, recurrent (daily) experiences of helplessness have catastrophically psychological ramifications, particularly during childhood development. Seligman's theory of learned helplessness claims in its origin that noncontingent environmental reinforcement responses to a person's behavior reduces the incentive motivation to control the outcome of an event, interferes with further event related outcome learning, and if the outcome is traumatically processed, produces fear as long as the subject is uncertain of the uncontrollability of the outcome, and then produces the state of helplessness and hopelessness (Seligman, 1975;

2008b, 2009a; Schoepf and Penberthy, 2010).

2006; McCullough, 2008; Schoepf et al., 2009a).

**adolescence**

Abramson et al., 1978).

**2.2.1 Cognitive-emotional level of organization and core pathology**

therefore not adequately influenced by relevant environmental incentives

interacting with the "Significant Others" during childhood (Schoepf et al., 2007, 2008a,

#### **The reward system is biased towards the expectation of punishment**

#### **The attentional system is biased towards unexpected events**

 The release of social fear is elicited by fast detection of any verbal- or nonverbal stimulus that predicts uncontrollability or unpredictability

Table 1. Double depression of the adult is usually associated with a refractory cognitiveemotional dilemma. What is observed at the beginning of treatment is an interpersonally avoidant patient with predomination of detached, distant and submissive behaviour. Instrumental avoidance of interpersonal encounter that holds the avoidance of the classical conditioned fear in abeyance is the predominant strategy. As a consequence the environment can not inform the patient (McCullough, 2007).

The intrapersonal effects become aware to the child at the point when the child is able to conclude that it doesn't matter what it does with a resulting independent of response expectation. From this time on the child is a prison holder of an ongoing "emotional survival" mode that is strongly coupled with a poor cognitive regulation of motivation. As a consequence the child is (in more cases than not) not able to develop a formal-operative mode of cognitive-emotional functioning in later developmental phases, cognitive-

Cognitive Behavioral Analysis System of Psychotherapy (CBASP):

behavioural functioning (McCullough, 2008).

technique administration (McCullough, 2010c).

when mentioning dysfunctional behavior (Schoepf et al., 2008b).

**2.4.1 The transference hypothesis**

**therapeutic relationship**

A Disorder-Oriented, Theory-Driven Psychotherapy Method from the "Third Generation"… 99

**2.3 The learned helplessness effect in chronic MDD without antecedent dysthymia**  The late-onset form of chronic MDD usually begins during the mid-20s and is associated with a first episode of MDD without antecedent dysthymia. The affected individuals report more often than not conditions without child maltreatment. They hold prison of a persisting "out-of-control" mood state that finally undercuts all of their previous assumptions of controllability. The affected individual therefore is a "hold prisoner" of a later learned helplessness state and "falls back" into a pre-operational mode of cognitive, emotional and

**2.4 The intentional use of the therapist's function as a reinforcer within the**

Integrating the concepts of various methods of first and second generation behavior therapists the CBASP is conceptualized in its origin as a single, integrative, and theorydriven third wave behavior therapy model that relies on modern learning theory to guide

With respect to the therapist's basic attitude, it is important that the CBASP therapist is highly aware of the fact that he or she merely helps to give birth to the functional learning processes and insights the patient experiences. In this sense, the therapist has to succeed in letting the patient "think and feel" during the process of becoming aware of proactive interpersonal and health-related behavior in the presence of the therapist. In order to effectively use the interventions of CBASP therapy, the therapist has to be trained and prepared to bring his or her own function as a reinforcer into the therapeutic relationship, and this has to be done in a personal, disciplined and responsible way. During the interaction between the patient and the therapist, the therapist's behavior should, on the one hand, guide and reinforce the patient's gain in knowledge yet, on the other hand, he or she should not interfere with the intrapersonal reinforcement of the patient's stress-induced behavioral patterns. The influence on the patient should not be such that he, due to positive interpersonal reinforcement, tries to present a maximum amount of successful behavior to the therapist, nor should the patient, as a result of positive (add a punisher) or negative (subtract a reinforcer) interactional punishment, avoid the therapist's negative reactions

One specific transference hypothesis in one of four transference areas that identifies the specific "hot spot" situations should be constructed as early as possible. The transference hypothesis is deduced using the "Significant Other History" (SOH) technique in CBASP (McCullough, 2006, 2008, 2010b; Neudeck et al., 2010). After reconstruction of the course of the depression (in the introductory session of therapy) the patient is asked to name his or her 3-6 " Significant Other's" in the following session and to work through the following three prompts for each "Significant Other" together with the therapist: (1) "What was it like growing up with or being around this person?" (2) Then, "how did he or her causally influence the course of your life in a way that is still present now?" (3) Then, "what is the emotional stamp you take from this relationship that informs who you are today?" In the original US-protocol the time instruction for the SOH-technique was one therapy session (second session). The time instruction was taken back by McCullough in the planning phase of German CBASP-studies (McCullough et al, 2008). According to the modified protocol the emotional reconstruction process in an antecedent-consequent format usually takes two to four sessions of therapy

emotional development is derailed. Uniformity, helplessness and hopelessness become the order of the day. In addition, the ability to recover after situational exposure is reduced and adverse life events are interpreted in pessimistic ways that produce, exacerbate, and prolong acute depressive symptoms (McCullough, 2007).

#### **<IP_ADDRESS> Interactional destructiveness of the learned helplessness effect**

Chronically depressed patients create depressing environments (Bandura, 1986). According to McCullough, the cognitive variable in double depression is the mental ability of the adult patient when he was a young child to learn to associate the emotions of fear and terror that accompanied maltreatment with behaviour that subsequently avoided the exacerbation of the negative emotions. From a communication perspective, associative learning of signalling stimuli and instrumentally learned rules mediate verbal and nonverbal responses (messages) that are regularly exchanged between two interactants. A "survival mode" with decreased cognitive regulation of motivation is associated with a severe disturbance of the dynamic person-environment interaction that maintains the learned helplessness effect. Social interaction is experienced as subjectively dissatisfying and is therefore avoided. Necessary adaptation in the period of adolescence and the adversities of later life cannot be dealt with in adequate ways. In addition, the negative socials evaluations and reactions the growing-up adolescence elicits from others provide social validation for a negative outlook on life. Three negative interactional effects are implicit within the conceptualization of learned helplessness.

#### **2.3 The learned helplessness effect in chronic MDD without antecedent dysthymia**

The late-onset form of chronic MDD usually begins during the mid-20s and is associated with a first episode of MDD without antecedent dysthymia. The affected individuals report more often than not conditions without child maltreatment. They hold prison of a persisting "out-of-control" mood state that finally undercuts all of their previous assumptions of controllability. The affected individual therefore is a "hold prisoner" of a later learned helplessness state and "falls back" into a pre-operational mode of cognitive, emotional and behavioural functioning (McCullough, 2008).

#### **2.4 The intentional use of the therapist's function as a reinforcer within the therapeutic relationship**

Integrating the concepts of various methods of first and second generation behavior therapists the CBASP is conceptualized in its origin as a single, integrative, and theorydriven third wave behavior therapy model that relies on modern learning theory to guide technique administration (McCullough, 2010c).

With respect to the therapist's basic attitude, it is important that the CBASP therapist is highly aware of the fact that he or she merely helps to give birth to the functional learning processes and insights the patient experiences. In this sense, the therapist has to succeed in letting the patient "think and feel" during the process of becoming aware of proactive interpersonal and health-related behavior in the presence of the therapist. In order to effectively use the interventions of CBASP therapy, the therapist has to be trained and prepared to bring his or her own function as a reinforcer into the therapeutic relationship, and this has to be done in a personal, disciplined and responsible way. During the interaction between the patient and the therapist, the therapist's behavior should, on the one hand, guide and reinforce the patient's gain in knowledge yet, on the other hand, he or she should not interfere with the intrapersonal reinforcement of the patient's stress-induced behavioral patterns. The influence on the patient should not be such that he, due to positive interpersonal reinforcement, tries to present a maximum amount of successful behavior to the therapist, nor should the patient, as a result of positive (add a punisher) or negative (subtract a reinforcer) interactional punishment, avoid the therapist's negative reactions when mentioning dysfunctional behavior (Schoepf et al., 2008b).

#### **2.4.1 The transference hypothesis**

98 Psychiatric Disorders – Worldwide Advances

emotional development is derailed. Uniformity, helplessness and hopelessness become the order of the day. In addition, the ability to recover after situational exposure is reduced and adverse life events are interpreted in pessimistic ways that produce, exacerbate, and prolong

Chronically depressed patients create depressing environments (Bandura, 1986). According to McCullough, the cognitive variable in double depression is the mental ability of the adult patient when he was a young child to learn to associate the emotions of fear and terror that accompanied maltreatment with behaviour that subsequently avoided the exacerbation of the negative emotions. From a communication perspective, associative learning of signalling stimuli and instrumentally learned rules mediate verbal and nonverbal responses (messages) that are regularly exchanged between two interactants. A "survival mode" with decreased cognitive regulation of motivation is associated with a severe disturbance of the dynamic person-environment interaction that maintains the learned helplessness effect. Social interaction is experienced as subjectively dissatisfying and is therefore avoided. Necessary adaptation in the period of adolescence and the adversities of later life cannot be dealt with in adequate ways. In addition, the negative socials evaluations and reactions the growing-up adolescence elicits from others provide social validation for a negative outlook on life. Three negative interactional effects are implicit within the conceptualization of

 Severely disturbed stimulus recognition: the established independent of response expectation results in the child's unawareness of the interactional relatedness to the environment in which it lives. The child becomes oblivious of its stimulus value and

does not see why it elicits negative responses on others (McCullough, 1988). Loss of social reinforcement: according to a biologically pre-determined personenvironment devil circulation the child has not available a sufficient quantity of reinforcing social events in the appropriate motivational state, that are able to accelerate the development of its cognitive-emotional organization. Instead, associative learning processes of stressful encounters with the "Significant Other's" and persistent deviant

interpersonal behavior is dominating about adaptive action-outcome learning. Deviant behaviours in social encounters: emotional deregulations lead to general interpersonal withdrawal, interpersonal detachment, interpersonal submission and interpersonal passivity. However, in persistent deviant interpersonal behaviour there is a lack of flexibility to use a broader range of interpersonal responses and behaviours which different interpersonal situations warrant. In its extreme form a severely maltreated child (that suffers of impaired development across diverse domains of biological and psychological functioning) has only a narrow range of one or two responses. The child's abnormal behaviour, then, consists of the rigid, constricted, and extreme behaviours that are often performed reflexively, whether they are appropriate to a situational encounter or not. As a consequence, non-corresponding reflexive responses without regard to there consequences often arouse stress and provide the child with an enduring vulnerability factor, placing it at great risk for future environmental maladaptation and psychopathology. The ongoing environment's negative response predisposes the child to stick in a repetitious state of learned

acute depressive symptoms (McCullough, 2007).

learned helplessness.

helplessness.

**<IP_ADDRESS> Interactional destructiveness of the learned helplessness effect**

One specific transference hypothesis in one of four transference areas that identifies the specific "hot spot" situations should be constructed as early as possible. The transference hypothesis is deduced using the "Significant Other History" (SOH) technique in CBASP (McCullough, 2006, 2008, 2010b; Neudeck et al., 2010). After reconstruction of the course of the depression (in the introductory session of therapy) the patient is asked to name his or her 3-6 " Significant Other's" in the following session and to work through the following three prompts for each "Significant Other" together with the therapist: (1) "What was it like growing up with or being around this person?" (2) Then, "how did he or her causally influence the course of your life in a way that is still present now?" (3) Then, "what is the emotional stamp you take from this relationship that informs who you are today?" In the original US-protocol the time instruction for the SOH-technique was one therapy session (second session). The time instruction was taken back by McCullough in the planning phase of German CBASP-studies (McCullough et al, 2008). According to the modified protocol the emotional reconstruction process in an antecedent-consequent format usually takes two to four sessions of therapy

Cognitive Behavioral Analysis System of Psychotherapy (CBASP):

during teaching "Situational Analysis".

Schoepf and McCullough 2009a).

**2.4.2 The stimulus character of the patient**

**2.5 CBASP`s cutting edges of behavior change**

well as the use of creating negative reinforcement situations.

the individual patient that interfere with his effective social management.

A Disorder-Oriented, Theory-Driven Psychotherapy Method from the "Third Generation"… 101

the patient after the emotional reconstruction process is finished (McCullough, 2006, 2008; Schoepf and McCullough 2009a). "Situational Analysis" (SA) is usually introduced during the fifth-to six session. We strongly recommend that working on the functionality teaching and the skill teaching level starts after the CBASP-therapist has worked out the specific transference hypothesis in the absence of the patient. It is our opinion, that the associated IDE technique is the major CBASP technique of "in-session acquisition learning" (Schoepf and McCullough, 2009a). IDE is most effective, if it focuses on "hot spot" events that occur

In addition, in order to use personalized meta-communicative interpersonal techniques (the second way of disciplined personal involvement used in CBASP therapy), it is important to validly measure the hidden emotional, cognitive, and behavioral responses the patient evokes in the therapist (in McCullough words the stimulus character of the patient), using the Kessler's Impact Message Inventory after the first session of therapy (Kiesler, 1983). The technique of "Contingent Personal Responsivity" (CPR) is used in instances where the therapist consequates the behaviour of the patient by disclosing personal responses and feelings produced in the therapist by the behaviour of the patient (McCullough, 2006, 2008;

The application of CBASP requires as well diagnostic skills as supervised practical therapeutic experience. The therapist should become accustomed to the use of motivational strategies through the exactly timed induction and the resolution of cognitive dissonance, as

The essential motif of the CBASP method is to focus the patient on what behaviour leads to what outcome (emotionally and interpersonal). In general, "Situational Analysis" (SA) focuses the patient on the consequences of his behaviour and teaches him what he does matters (empowerment), as well teaches him adaptive social skills (functionality teaching and skills teaching dimension of the CBASP). Furthermore, the procedure of SA assists the therapist in identifying and addressing the specific cognitive and behavioural problems of

In addition, personal involvement techniques are linked both to the functionality teachingand the skills teaching dimension. A unique type of therapist intervention, called "Disciplined Personal Involvement"(DPI), advocates a non-neutral role for the psychotherapist (interpersonal dimension of the CBASP). The techniques of DPI are based on early concepts of objective counter transference and interpersonal reactions that provide the authorization of the CBASP therapist for using self-disclosures with a maximum impact: to create an interpersonal "safety place" and to transfer the experiences outside the therapy to others, to connect the patient perceptually with his environment, to modify dysfunctional behaviour contingently, and to address/heal developmental trauma arising from negative experiences with maltreating significant other's (Schoepf and McCullough, 2009). Through DPI, the deeply personal nature of the therapist-patient relationship is put into the foreground of therapeutic efficacy as both a moderator variable of in-session acquisition learning and an alternative to therapist neutrality. In comparison to other therapy models the interventions of DPI are deeper and more personal - than sensitive participation in

(Schoepf and McCullough 2009a, Schoepf et al., 2010). The SOH technique is more often than not hurtful for the early-onset patient. The patient has to be informed that negative feelings like fear, pain and sadness may be evoked and that the therapist is blind for "hot spot" situations at this time of therapy (McCullough, 2008; Schoepf and McCullough, 2009a). It is important to note, that a two-step focussing strategy is applied (prompts one and two) before the therapist helps in step three the patient to construct the stamp. The duration of the SOH exercise usually takes at least thirty minutes with respect to one "Significant Other". After the emotional reconstruction process is finished the therapist reviews in the absence of the patient the leading interpersonal theme in which the patient interacted with his "Significant Other's". The interpersonal-emotional theme reflects the early learning history of the patient and is derived from these "stamps" or causal theory conclusions (McCullough et al., 2010b). McCullough (2000, 2006, 2010b) assumes four transference areas of interaction in chronically depressed patients that, from the perspective of developmental psychology, play an important role in the patient's relationship with significant others. His theoretical considerations concerning the transference hypothesis refer to the concept of "tacit knowledge**"**(Polanyi, 1966) and the idea of "reasoning based on implicit causal theories" (Nisbett and Wilson, 1977). In accordance with these assumptions, learning processes and instrumentally learned interpersonal rules that were developed during "toxic experienced" developmental conditions may have caused implicit shifts of attention and expectation. These shifts may have helped the growing-up child as "emotional surviving strategies" to decrease the contact with interpersonal events in the specific "hot spot area" that are expected to have negative outcomes. Automatic conditioned patterns of interpersonal behavior are elicited and executed regularly in "hot spot" situations. This rigidly ruled behaviour usually does not correspond to the present situation, arouses stress and provides the patient with a social disadvantage.

Specifically, McCullough (2000) describes working with the construct of transference as an exercise in "focused attention." The transference hypothesis differs from Freud's concept of transference since it can be actively acted out in session with the therapist and then processed within the "Interpersonal Discrimination Exercise" (IDE). From a learning theory perspective the transference hypothesis includes the interpersonal content that most likely reflects the patient's expectancy of the therapist's reactions toward the individual (McCullough et al., 2010b). The four transference areas of interpersonal dysfunction in that "hot spots" occur are:

Whenever a "hot spot" situation occurs within a therapy session, the transference hypothesis is made explicit through IDE work, i.e. the first way of disciplined personal involvement used in CBASP therapy (McCullough, 2006, 2008). It is important to note for the reader that according to the specific CBASP protocol the patient manual is distributed to the patient after the emotional reconstruction process is finished (McCullough, 2006, 2008; Schoepf and McCullough 2009a). "Situational Analysis" (SA) is usually introduced during the fifth-to six session. We strongly recommend that working on the functionality teaching and the skill teaching level starts after the CBASP-therapist has worked out the specific transference hypothesis in the absence of the patient. It is our opinion, that the associated IDE technique is the major CBASP technique of "in-session acquisition learning" (Schoepf and McCullough, 2009a). IDE is most effective, if it focuses on "hot spot" events that occur during teaching "Situational Analysis".

#### **2.4.2 The stimulus character of the patient**

100 Psychiatric Disorders – Worldwide Advances

(Schoepf and McCullough 2009a, Schoepf et al., 2010). The SOH technique is more often than not hurtful for the early-onset patient. The patient has to be informed that negative feelings like fear, pain and sadness may be evoked and that the therapist is blind for "hot spot" situations at this time of therapy (McCullough, 2008; Schoepf and McCullough, 2009a). It is important to note, that a two-step focussing strategy is applied (prompts one and two) before the therapist helps in step three the patient to construct the stamp. The duration of the SOH exercise usually takes at least thirty minutes with respect to one "Significant Other". After the emotional reconstruction process is finished the therapist reviews in the absence of the patient the leading interpersonal theme in which the patient interacted with his "Significant Other's". The interpersonal-emotional theme reflects the early learning history of the patient and is derived from these "stamps" or causal theory conclusions (McCullough et al., 2010b). McCullough (2000, 2006, 2010b) assumes four transference areas of interaction in chronically depressed patients that, from the perspective of developmental psychology, play an important role in the patient's relationship with significant others. His theoretical considerations concerning the transference hypothesis refer to the concept of "tacit knowledge**"**(Polanyi, 1966) and the idea of "reasoning based on implicit causal theories" (Nisbett and Wilson, 1977). In accordance with these assumptions, learning processes and instrumentally learned interpersonal rules that were developed during "toxic experienced" developmental conditions may have caused implicit shifts of attention and expectation. These shifts may have helped the growing-up child as "emotional surviving strategies" to decrease the contact with interpersonal events in the specific "hot spot area" that are expected to have negative outcomes. Automatic conditioned patterns of interpersonal behavior are elicited and executed regularly in "hot spot" situations. This rigidly ruled behaviour usually does not correspond to the present situation, arouses stress and provides the patient with a social disadvantage. Specifically, McCullough (2000) describes working with the construct of transference as an exercise in "focused attention." The transference hypothesis differs from Freud's concept of transference since it can be actively acted out in session with the therapist and then processed within the "Interpersonal Discrimination Exercise" (IDE). From a learning theory perspective the transference hypothesis includes the interpersonal content that most likely reflects the patient's expectancy of the therapist's reactions toward the individual (McCullough et al., 2010b). The four transference areas of interpersonal dysfunction in that

1. in-session moments of intimacy (either felt by the patient or the therapist) that evoke in the patient (Pavlovian) fear of being physically or emotionally abused (intimacy area), 2. in-session events in which the patient discloses emotional needs toward the therapist that evoke in the patient (Pavlovian) fear of being ridiculed or censored (disclosure of

3. in-session events during which the patient makes mistakes towards the therapist (e.g., not doing his or her homework or being unable to solve problems presented during therapy sessions) that evoke in the patient (Pavlovian) fear of severe physical or

4. in-session events in which the patient expresses negative affects towards the therapist that evoke in the patient (Pavlovian) fear of punishment (expression of negative affect area). Whenever a "hot spot" situation occurs within a therapy session, the transference hypothesis is made explicit through IDE work, i.e. the first way of disciplined personal involvement used in CBASP therapy (McCullough, 2006, 2008). It is important to note for the reader that according to the specific CBASP protocol the patient manual is distributed to

emotional punishment (mistake and failure area),

"hot spots" occur are:

need area),

In addition, in order to use personalized meta-communicative interpersonal techniques (the second way of disciplined personal involvement used in CBASP therapy), it is important to validly measure the hidden emotional, cognitive, and behavioral responses the patient evokes in the therapist (in McCullough words the stimulus character of the patient), using the Kessler's Impact Message Inventory after the first session of therapy (Kiesler, 1983). The technique of "Contingent Personal Responsivity" (CPR) is used in instances where the therapist consequates the behaviour of the patient by disclosing personal responses and feelings produced in the therapist by the behaviour of the patient (McCullough, 2006, 2008; Schoepf and McCullough 2009a).

#### **2.5 CBASP`s cutting edges of behavior change**

The application of CBASP requires as well diagnostic skills as supervised practical therapeutic experience. The therapist should become accustomed to the use of motivational strategies through the exactly timed induction and the resolution of cognitive dissonance, as well as the use of creating negative reinforcement situations.

The essential motif of the CBASP method is to focus the patient on what behaviour leads to what outcome (emotionally and interpersonal). In general, "Situational Analysis" (SA) focuses the patient on the consequences of his behaviour and teaches him what he does matters (empowerment), as well teaches him adaptive social skills (functionality teaching and skills teaching dimension of the CBASP). Furthermore, the procedure of SA assists the therapist in identifying and addressing the specific cognitive and behavioural problems of the individual patient that interfere with his effective social management.

In addition, personal involvement techniques are linked both to the functionality teachingand the skills teaching dimension. A unique type of therapist intervention, called "Disciplined Personal Involvement"(DPI), advocates a non-neutral role for the psychotherapist (interpersonal dimension of the CBASP). The techniques of DPI are based on early concepts of objective counter transference and interpersonal reactions that provide the authorization of the CBASP therapist for using self-disclosures with a maximum impact: to create an interpersonal "safety place" and to transfer the experiences outside the therapy to others, to connect the patient perceptually with his environment, to modify dysfunctional behaviour contingently, and to address/heal developmental trauma arising from negative experiences with maltreating significant other's (Schoepf and McCullough, 2009). Through DPI, the deeply personal nature of the therapist-patient relationship is put into the foreground of therapeutic efficacy as both a moderator variable of in-session acquisition learning and an alternative to therapist neutrality. In comparison to other therapy models the interventions of DPI are deeper and more personal - than sensitive participation in

Cognitive Behavioral Analysis System of Psychotherapy (CBASP):

After this the three phases of IDE are consecutively carried out.

**Interpersonal Discrimination Exercise (IDE)**

**NEGATIVE PHASE**

(Schoepf et al., 2007). **POSITIVE PHASE**

**HEALING PHASE**

the patient.

A Disorder-Oriented, Theory-Driven Psychotherapy Method from the "Third Generation"… 103

Table 3 represents the major DPI technique of in-session acquisition learning according to the specific protocol in outpatients, the "Interpersonal Discrimination Exercise" (IDE).

Learning context: the therapist directs the patient's focus of attention to the just happened "hot spot"in-session event/moment and writes the"hot spot" behavior on the flip-chart.

The patient is gently asked to recall a typical past social interaction with one or two of his maltreating "Significant Other's" in a similar situation. In the cognitive form the patient has to describe the behavioral consequences on himself caused by the behavior of his significant other. In particular bad thoughts are evoked through tacit knowledge. In the emotional form the patient is additionally gently asked to re-experience the associated hurtful (refractory) emotions in the presence of the therapist. In particular negative feelings like fear, pain and sadness are evoked. Counter-conditioning according to the principle of reciprocal inhibition takes place by the benevolent therapist's reaction

After the intensity of negative thoughts and emotions is decreased the patient is gently asked to describe his perception of the therapist's reactions. Furthermore, he has to characterize the feelings that have been evoked by the current incident with the therapist. He is then asked to compare the therapist's behavior to the recalled behavior (and the corresponding emotion in the emotional form of IDE) of his significant others in a similar situation. The felt distress of the patient usually decreases at this moment of the exercise.

Sensitive to the timing and the magnitude of the felt decrease of distress in the healing phase of the IDE, the patient is encouraged by the therapist to identify the contrast between the therapist's behavior and the significant other's' behavior. "Automatically" there results a felt increase of the potency of the therapist to specifically reduce interpersonal distress during the experienced "hot spot" situation and a new interpersonal reality of the therapist-patient relationship comes into being meaningful to

Table 3. Negative phase, positive phase and healing phase in IDE. The starting point is defined by the presence of an in-session "hot-spot" event/moment. In the cognitive form of IDE counter-conditioning of cognitive evoked (Pavlovian) fear is applied in the negative phase. The principle of sensitization is started in the positive phase and is increased in the healing phase (Neudeck et al., 2010). In the emotional form of IDE the principle of counterconditioning of re-experienced (Pavlovian) fear predominates within all IDE phases. A strong feeling of "safety" within the therapy dyad results that usually elevates the probability of generalizing outside of therapy to the patient's other relationships**.**

The self-disclosures are carefully timed and choreographed by the CBASP-therapist to strategically counteract the patient's destructive interpersonal basic assumptions he has experienced from past negative interactions. In McCullough's words, the job of the therapist is to become "a problem for the patient". That is, patients should experience difficulties integrating the therapist's interpersonal messages of caring and concern into their negative

supportive therapy, - than turning the patient's attention to the analysis of counter transference reactions in psychodynamic orientated approaches, - than the use of metacommunication to modify action-counteraction response patterns in interpersonal therapy, than the analyses and change of maladaptive behaviour in the awakening effect based behavioural approaches or – than the work of cognitive restructuring processes in cognitive therapy. DPI (especially IDE) basically influences the process of self-update of the patient. Table 2 represents the mayor CBASP technique of behaviour change in outpatients according to the specific protocol, the "Situational Analysis" (SA).

#### **Situational Analysis (SA)**

Learning context: the patient usually brings into therapy a completed SA worksheet of either a distressing or pleasant daily living interaction that happened during the last week. The review of the worksheet is usually carried out in two consecutively phases on the flip-chart (some investigators additionally distinguish a learning and transfer phase for didactic reasons).

#### **ELICITATION PHASE**

In the first step the interactional (social) event has to be described by the patient from an observational-describing focus. The beginning and the end point have to be clearly addressed.

During the second step the patient's cognitive-emotional attribution is elicited. Relevant and accurate forms represent either self-referring (self-reflecting) emotional or cognitive interpretations, as well as describing (interactional) interpretations and action interpretations.

In the following three steps the verbal and nonverbal interactional responses, the actual outcome (AO) in behavioural terms, and the way the patient wanted to behave in the situation – his desired outcome (DO) - are elicited. In the case of a distressing event a clear discrepancy appears between the patient's AO and DO. At this point a condition of negative-reinforcement is created by the therapist. The induced cognitive dissonance is later reduced by the finding of more adaptive strategies.

The last two steps are important for the patient in order to become aware of the discrepancy between his AO and DO. The patient has first to decide if he got what he wanted by comparing his AO with his DO. Then he is gently asked to explain why he did not behave in the way he wanted to behave.

#### **REMEDIATION PHASE**

In this phase, the therapist and patient work on solutions for the patient, to behave in a way that is efficient with respect to his DO.

Shaping of functional interpretations (first step) as well as shaping of missing behavioural aspects of the DO (second step), learning summary (third step), transfer to a future situation and skill training (fourth step) amplifies both the new element of reaction and experience as the conditional relationship between positive efficacy beliefs and positive outcome expectancies.

Transfer is maximized because the target situations come out of the daily living experiences of the patient.

Table 2. Description of the elicitation and remediation phase in SA.

Table 3 represents the major DPI technique of in-session acquisition learning according to the specific protocol in outpatients, the "Interpersonal Discrimination Exercise" (IDE).

#### **Interpersonal Discrimination Exercise (IDE)**

Learning context: the therapist directs the patient's focus of attention to the just happened "hot spot"in-session event/moment and writes the"hot spot" behavior on the flip-chart. After this the three phases of IDE are consecutively carried out.

#### **NEGATIVE PHASE**

102 Psychiatric Disorders – Worldwide Advances

supportive therapy, - than turning the patient's attention to the analysis of counter transference reactions in psychodynamic orientated approaches, - than the use of metacommunication to modify action-counteraction response patterns in interpersonal therapy, than the analyses and change of maladaptive behaviour in the awakening effect based behavioural approaches or – than the work of cognitive restructuring processes in cognitive therapy. DPI (especially IDE) basically influences the process of self-update of the patient. Table 2 represents the mayor CBASP technique of behaviour change in outpatients

Learning context: the patient usually brings into therapy a completed SA worksheet of either a distressing or pleasant daily living interaction that happened during the last week. The review of the worksheet is usually carried out in two consecutively phases on the flip-chart (some investigators additionally distinguish a learning and transfer phase

In the first step the interactional (social) event has to be described by the patient from an observational-describing focus. The beginning and the end point have to be clearly

During the second step the patient's cognitive-emotional attribution is elicited. Relevant and accurate forms represent either self-referring (self-reflecting) emotional or cognitive interpretations, as well as describing (interactional) interpretations and action

In the following three steps the verbal and nonverbal interactional responses, the actual outcome (AO) in behavioural terms, and the way the patient wanted to behave in the situation – his desired outcome (DO) - are elicited. In the case of a distressing event a clear discrepancy appears between the patient's AO and DO. At this point a condition of negative-reinforcement is created by the therapist. The induced cognitive dissonance is

The last two steps are important for the patient in order to become aware of the discrepancy between his AO and DO. The patient has first to decide if he got what he wanted by comparing his AO with his DO. Then he is gently asked to explain why he did

In this phase, the therapist and patient work on solutions for the patient, to behave in a

Shaping of functional interpretations (first step) as well as shaping of missing behavioural aspects of the DO (second step), learning summary (third step), transfer to a future situation and skill training (fourth step) amplifies both the new element of reaction and experience as the conditional relationship between positive efficacy beliefs and positive

Transfer is maximized because the target situations come out of the daily living

according to the specific protocol, the "Situational Analysis" (SA).

later reduced by the finding of more adaptive strategies.

Table 2. Description of the elicitation and remediation phase in SA.

not behave in the way he wanted to behave.

way that is efficient with respect to his DO.

**REMEDIATION PHASE**

outcome expectancies.

experiences of the patient.

**Situational Analysis (SA)**

for didactic reasons). **ELICITATION PHASE**

addressed.

interpretations.

The patient is gently asked to recall a typical past social interaction with one or two of his maltreating "Significant Other's" in a similar situation. In the cognitive form the patient has to describe the behavioral consequences on himself caused by the behavior of his significant other. In particular bad thoughts are evoked through tacit knowledge. In the emotional form the patient is additionally gently asked to re-experience the associated hurtful (refractory) emotions in the presence of the therapist. In particular negative feelings like fear, pain and sadness are evoked. Counter-conditioning according to the principle of reciprocal inhibition takes place by the benevolent therapist's reaction (Schoepf et al., 2007).

#### **POSITIVE PHASE**

After the intensity of negative thoughts and emotions is decreased the patient is gently asked to describe his perception of the therapist's reactions. Furthermore, he has to characterize the feelings that have been evoked by the current incident with the therapist. He is then asked to compare the therapist's behavior to the recalled behavior (and the corresponding emotion in the emotional form of IDE) of his significant others in a similar situation. The felt distress of the patient usually decreases at this moment of the exercise.

#### **HEALING PHASE**

Sensitive to the timing and the magnitude of the felt decrease of distress in the healing phase of the IDE, the patient is encouraged by the therapist to identify the contrast between the therapist's behavior and the significant other's' behavior. "Automatically" there results a felt increase of the potency of the therapist to specifically reduce interpersonal distress during the experienced "hot spot" situation and a new interpersonal reality of the therapist-patient relationship comes into being meaningful to the patient.

Table 3. Negative phase, positive phase and healing phase in IDE. The starting point is defined by the presence of an in-session "hot-spot" event/moment. In the cognitive form of IDE counter-conditioning of cognitive evoked (Pavlovian) fear is applied in the negative phase. The principle of sensitization is started in the positive phase and is increased in the healing phase (Neudeck et al., 2010). In the emotional form of IDE the principle of counterconditioning of re-experienced (Pavlovian) fear predominates within all IDE phases. A strong feeling of "safety" within the therapy dyad results that usually elevates the probability of generalizing outside of therapy to the patient's other relationships**.**

The self-disclosures are carefully timed and choreographed by the CBASP-therapist to strategically counteract the patient's destructive interpersonal basic assumptions he has experienced from past negative interactions. In McCullough's words, the job of the therapist is to become "a problem for the patient". That is, patients should experience difficulties integrating the therapist's interpersonal messages of caring and concern into their negative

Cognitive Behavioral Analysis System of Psychotherapy (CBASP):

**<IP_ADDRESS> Skinner's radical behaviorist approach to operant conditioning**

goals.

performance (Schoepf et al., 2007).

family (Piaget, 1973).

Schoepf and Penberthy, 2010).

2009a).

et al., 2009a).

A Disorder-Oriented, Theory-Driven Psychotherapy Method from the "Third Generation"… 105

Within CBASP, Winnicott's concept constitutes the most important basic assumption, establishing how, with the help of DPI, the patient's resistance that is caused by reactions of negative transference is dealt with and the integration of traumatic learning experiences into his or her self-image is achieved. This implies according to McCullough that the CBASP therapist (1) applies objective counter-transference as a vehicle of in-session change, (2) is able to be oneself with the patient in the therapy, (3) salubriously uses personal responsivity, (4) arranges contingencies so that the patient can learn, (5) makes moment-tomoment decisions with respect to CBASP treatment goals, (6) self-monitors the patient's moment-to-moment verbal- and nonverbal messages, and (7) is focused in supervision on his non-reflected verbal- and nonverbal messages that interfere with CBASP treatment

Closely related to Skinner's basic assumptions (Skinner, 1953), the principles of modern learning theory applied to the behavior-reinforcer-relation with respect to the implicit

During CBASP-therapy, the principle of operant conditioning and the principles of consequence-based interventions are applied in most therapy situations. This is done in order to (1) activate and modulate executive performance, (2) to systematically practice adaptive goal-directed behavior with the patient, (3) and to improve his or her ability to think and act in formal-operational ways by enhancing perceptive and interpretative

**<IP_ADDRESS> Piaget's systems-theoretical biological theory of cognitive-emotional development**  Piaget`s theory claims in its origin that a level of formal-operative functioning is achieved through a childhood condition that is associated with competent and caring adults in the

In CBASP, the basic assumptions of Piaget's developmental theory play a crucial role in explaining global developmental deficits of cognitive-emotional organization in double depression. Furthermore, Piaget`s theory serves as a theoretical foundation for the systematic construction of new stimulus-response behavior patterns within the therapeutic zone, and for the automatic generalization of a new learned element outside the therapeutic space through the mechanisms of functional and generalizing assimilation (Schoepf et al.,

**<IP_ADDRESS> Seligman's revised theory of learned helplessness and the role of attributional**

Seligman's theoretical idea that organisms exposed to inescapable and unavoidable shocks learn that their actions do not control environmental outcomes (Seligman, 1975; Abramson et al., 1978) formulates the theoretical foundation for the cognitive- and behavioral contributor of the reciprocal model of causation in double depression (Schoepf et al. 2008a;

In addition, the "independent of response expectation" of the chronically depressed patient justifies (1) the necessity of continuous performed moment to moment related feedback in a personalized form, and (2) discriminatory exercises between stimulus and response as well as response and consequence, using simple situational related contrast techniques (Schoepf

**style with respect to cross-situational generalization**

regulation of situational outcome expectations are crucial to CBASP (Bouton, 2007).

interpersonal expectations. The sincerity, honesty, genuineness and staying power of the therapist makes it difficult for the patient to escape these interactions by using the old learned distancing strategies like "counterattacking or withdrawing" (Schoepf and McCullough, 2009). Thus, the CBASP-therapist should be systematically prepared to demonstrate his or her own positive or negative feelings that all have message value to the patient within a defined therapeutic situation. This has to be done in a responsible way that is both theory-driven and controlled (McCullough, 2006).

#### **2.5.1 Principles of intervention**

The learning CBASP therapist should acquire a thorough understanding of the theoretical foundations of CBASP that are described in the following passage. In addition to G Prouty's pretherapy model for schizophrenic patients and KG Bailey's paleopsychological assumptions (McCullough, 2006), the CBASP therapy model specifically incorporates the following nine theoretical approaches from psychology.

The approaches and the associated interventions are listed in order by publication date of their respective most influential publication, including a brief summary of the relevant therapy strategies and mechanisms of actions used in CBASP.

#### **<IP_ADDRESS> Pavlov's theory of classical conditioning and his concept of transmarginal inhibition and the paradoxical phase**

Linked to Pavlov's assumptions (Pavlov, 1941) are the principles of modern learning theory with respect to the signal-reinforcer-relationship in relation to the implicit regulation of attentional control (Bouton, 2007).

In CBASP, associative learning of intrapersonal-interpersonal (Pavlovian) fear through the mechanism of classical conditioning represents the "stimulus input" of the hypothetical construct of double depression as a refractory mood disorder. The construct represents the theoretical basis for: (1) guiding of the patient's attention control in the context of surveying the patient's "emotional learning history" (McCullough et. al., 2010b); (2) counter conditioning (Pavlovian) fear (Schoepf et al., 2008b); and (3) the application of systemic desensitization in order to modify maladjusted and destructive interpersonal types of behavior (Schoepf et al., 2009, 2011).

#### **<IP_ADDRESS> Mowrer's two-factor theory on the generalization and inhibition of fear**

Mowrer's theory states in its origin that classical conditioned fear learning allows warning stimuli to evoke conditioned fear that motivates avoidance behavior that provides reinforcement of the instrumental avoidance response through the reduction of fear (Mowrer, 1947).

The principle of avoidance learning is of crucial importance (1) to both the CBASP-therapist and the CBASP-supervisor, defining the course of treatment with respect to the causal direction between the stimulus that reduces fear (provided by the therapist) and the inhibition of the stimulus that was conditioned in relation to the patient's "Significant Other's"; and (2) the specific therapeutic intervention and the possibility to change, inside or outside of therapy (Schoepf et. al., 2009a).

#### **<IP_ADDRESS> Winnicott's concept of objective counter transference**

According to Winnicott "objective" counter transference is the constricted feelings, attitudes, and reactions of a therapist induced by a patient (Winnicott, 1949).

interpersonal expectations. The sincerity, honesty, genuineness and staying power of the therapist makes it difficult for the patient to escape these interactions by using the old learned distancing strategies like "counterattacking or withdrawing" (Schoepf and McCullough, 2009). Thus, the CBASP-therapist should be systematically prepared to demonstrate his or her own positive or negative feelings that all have message value to the patient within a defined therapeutic situation. This has to be done in a responsible way that

The learning CBASP therapist should acquire a thorough understanding of the theoretical foundations of CBASP that are described in the following passage. In addition to G Prouty's pretherapy model for schizophrenic patients and KG Bailey's paleopsychological assumptions (McCullough, 2006), the CBASP therapy model specifically incorporates the

The approaches and the associated interventions are listed in order by publication date of their respective most influential publication, including a brief summary of the relevant

Linked to Pavlov's assumptions (Pavlov, 1941) are the principles of modern learning theory with respect to the signal-reinforcer-relationship in relation to the implicit regulation of

In CBASP, associative learning of intrapersonal-interpersonal (Pavlovian) fear through the mechanism of classical conditioning represents the "stimulus input" of the hypothetical construct of double depression as a refractory mood disorder. The construct represents the theoretical basis for: (1) guiding of the patient's attention control in the context of surveying the patient's "emotional learning history" (McCullough et. al., 2010b); (2) counter conditioning (Pavlovian) fear (Schoepf et al., 2008b); and (3) the application of systemic desensitization in order to modify maladjusted and destructive interpersonal types of

Mowrer's theory states in its origin that classical conditioned fear learning allows warning stimuli to evoke conditioned fear that motivates avoidance behavior that provides reinforcement of the instrumental avoidance response through the reduction of fear

The principle of avoidance learning is of crucial importance (1) to both the CBASP-therapist and the CBASP-supervisor, defining the course of treatment with respect to the causal direction between the stimulus that reduces fear (provided by the therapist) and the inhibition of the stimulus that was conditioned in relation to the patient's "Significant Other's"; and (2) the specific therapeutic intervention and the possibility to change, inside or

According to Winnicott "objective" counter transference is the constricted feelings, attitudes,

**<IP_ADDRESS> Pavlov's theory of classical conditioning and his concept of transmarginal**

**<IP_ADDRESS> Mowrer's two-factor theory on the generalization and inhibition of fear**

is both theory-driven and controlled (McCullough, 2006).

following nine theoretical approaches from psychology.

therapy strategies and mechanisms of actions used in CBASP.

**2.5.1 Principles of intervention**

**inhibition and the paradoxical phase**

attentional control (Bouton, 2007).

behavior (Schoepf et al., 2009, 2011).

outside of therapy (Schoepf et. al., 2009a).

**<IP_ADDRESS> Winnicott's concept of objective counter transference**

and reactions of a therapist induced by a patient (Winnicott, 1949).

(Mowrer, 1947).

Within CBASP, Winnicott's concept constitutes the most important basic assumption, establishing how, with the help of DPI, the patient's resistance that is caused by reactions of negative transference is dealt with and the integration of traumatic learning experiences into his or her self-image is achieved. This implies according to McCullough that the CBASP therapist (1) applies objective counter-transference as a vehicle of in-session change, (2) is able to be oneself with the patient in the therapy, (3) salubriously uses personal responsivity, (4) arranges contingencies so that the patient can learn, (5) makes moment-tomoment decisions with respect to CBASP treatment goals, (6) self-monitors the patient's moment-to-moment verbal- and nonverbal messages, and (7) is focused in supervision on his non-reflected verbal- and nonverbal messages that interfere with CBASP treatment goals.

#### **<IP_ADDRESS> Skinner's radical behaviorist approach to operant conditioning**

Closely related to Skinner's basic assumptions (Skinner, 1953), the principles of modern learning theory applied to the behavior-reinforcer-relation with respect to the implicit regulation of situational outcome expectations are crucial to CBASP (Bouton, 2007).

During CBASP-therapy, the principle of operant conditioning and the principles of consequence-based interventions are applied in most therapy situations. This is done in order to (1) activate and modulate executive performance, (2) to systematically practice adaptive goal-directed behavior with the patient, (3) and to improve his or her ability to think and act in formal-operational ways by enhancing perceptive and interpretative performance (Schoepf et al., 2007).

#### **<IP_ADDRESS> Piaget's systems-theoretical biological theory of cognitive-emotional development**

Piaget`s theory claims in its origin that a level of formal-operative functioning is achieved through a childhood condition that is associated with competent and caring adults in the family (Piaget, 1973).

In CBASP, the basic assumptions of Piaget's developmental theory play a crucial role in explaining global developmental deficits of cognitive-emotional organization in double depression. Furthermore, Piaget`s theory serves as a theoretical foundation for the systematic construction of new stimulus-response behavior patterns within the therapeutic zone, and for the automatic generalization of a new learned element outside the therapeutic space through the mechanisms of functional and generalizing assimilation (Schoepf et al., 2009a).

#### **<IP_ADDRESS> Seligman's revised theory of learned helplessness and the role of attributional style with respect to cross-situational generalization**

Seligman's theoretical idea that organisms exposed to inescapable and unavoidable shocks learn that their actions do not control environmental outcomes (Seligman, 1975; Abramson et al., 1978) formulates the theoretical foundation for the cognitive- and behavioral contributor of the reciprocal model of causation in double depression (Schoepf et al. 2008a; Schoepf and Penberthy, 2010).

In addition, the "independent of response expectation" of the chronically depressed patient justifies (1) the necessity of continuous performed moment to moment related feedback in a personalized form, and (2) discriminatory exercises between stimulus and response as well as response and consequence, using simple situational related contrast techniques (Schoepf et al., 2009a).

Cognitive Behavioral Analysis System of Psychotherapy (CBASP):

which it is achieved (Wechsler, 1961; McCullough, 2006).

regulation of emotions can occur.

down" effects on stimulus recognition.

limbic and limbic-cortical structures is strong.

and further examples, see Schoepf et al., 2007).

enhanced, thereby facilitating reflexive behavior once more.

**2.7.1 Mechanisms of action of bottom-up strategies**

A Disorder-Oriented, Theory-Driven Psychotherapy Method from the "Third Generation"… 107