Cognitive Behavioral Analysis System of Psychotherapy (CBASP)

1  — Well-Supported by Research Evidence
Medium

About This Program

Target Population: Chronically depressed adults

Program Overview

CBASP has been developed solely for the treatment of the chronic depressive adults. Most patients present with maltreatment developmental histories that impede normal cognitive-emotive growth in the ability to related socially with others. Hence, patients begin treatment functioning in a primitive manner meaning their thought and feeling patterns are not very organized, self-centered, and prelogical, and they talk to therapists in a monologic manner. Chronic depression is essentially a chronic mood disorder and does not fit the typical description of major depression that comes and goes as a "thinking disorder."

At the outset of psychotherapy, the patient is interpersonally detached and withdrawn and is perceptually disconnected from the actual consequences of their own behavior. The general fiction they live out is "it doesn't matter what I do, nothing will change." Three techniques are administered to demonstrate to patients that the way they behave with others has consequences (Situational Analysis); to help patients discriminate the psychotherapist from toxic Significant Others who have hurt them (Interpersonal Discrimination Exercise); and to modify in-session maladaptive behavior that precludes the therapist from administering treatment (Contingent Personal Responsivity). The CBASP therapist role is interpersonally active and administered in a disciplined personal involved manner.

Program Goals

The program representative did not provide information about the program’s goals.

Logic Model

The program representative did not provide information about a Logic Model for Cognitive Behavioral Analysis System of Psychotherapy (CBASP).

Essential Components

The essential components of Cognitive Behavioral Analysis System of Psychotherapy (CBASP) include:

  • A learning model where patients learn skills to operationalized criterion
  • Grounded upon a Person x Environment Causal Determinant Model of Behavior: Behavior = f (P X E)
  • Patients:
    • Learn they produce the interpersonal problems they complain about during the therapy hour
    • Learn to enact a situational problem-solving algorithm
    • Learn to discriminate emotionally the psychotherapist from toxic Significant Others
  • Therapist Role:
    • Disciplined personal involvement role to counter toxic interpersonal experiences leading to interpersonal avoidance/withdrawal

Program Delivery

Adult Services

Cognitive Behavioral Analysis System of Psychotherapy (CBASP) directly provides services to adults (regardless of whether they are parents or caregivers) and addresses the following:

  • Depression

Recommended Intensity:

One hour-long weekly session

Recommended Duration:

30 sessions (7-8 months)

Delivery Settings

This program is typically conducted in a(n):

  • Hospital
  • Outpatient Clinic
  • Community-based Agency / Organization / Provider

Homework

Cognitive Behavioral Analysis System of Psychotherapy (CBASP) includes a homework component:

Patients complete the Coping Survey Questionnaire (CSQ) each session where they report on one stress situation that is then addressed in the Situational Analysis (SA).

Languages

Cognitive Behavioral Analysis System of Psychotherapy (CBASP) has materials available in languages other than English:

Chinese, German, Japanese, Spanish

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

Offices for therapy sessions with clients

Manuals and Training

Prerequisite/Minimum Provider Qualifications

Post Degree PhD Psychologists, MSW Social Workers, and Post Residency Psychiatrists in addition to experience treating the chronically depressed patient

Manual Information

There is a manual that describes how to deliver this program.

Training Information

There is training available for this program.

Training Contacts:
Training Type/Location:

Varies by client

Number of days/hours:

One-Week Intensive Training Workshop (Monday through Friday, 9:00 AM - 5:00 PM)

Implementation Information

Pre-Implementation Materials

The program representative did not provide information about pre-implementation materials.

Formal Support for Implementation

The program representative did not provide information about formal support for implementation of Cognitive Behavioral Analysis System of Psychotherapy (CBASP).

Fidelity Measures

The program representative did not provide information about fidelity measures of Cognitive Behavioral Analysis System of Psychotherapy (CBASP).

Implementation Guides or Manuals

The program representative did not provide information about implementation guides or manuals for Cognitive Behavioral Analysis System of Psychotherapy (CBASP).

Research on How to Implement the Program

The program representative did not provide information about research conducted on how to implement Cognitive Behavioral Analysis System of Psychotherapy (CBASP).

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Keller, M. B., McCullough, J. P., Klein, D. N., Arnow, B., Dunner, D. L., Gelenberg, A. J., Markowitz, J. C., Nemeroff, C. B., Russell, J. M., Thase, M. E., Trivedi, M. H., Blalock, J. A., Borian, F. E., Jody, D. N., DeBattista, C., Koran, L. M., Schatzberg, A. F., Fawcett, J., Hirschfeld, R. M. A.,… Zajecka, J. (2000). A comparison of nefazodone, the Cognitive Behavioral Analysis System of Psychotherapy, and their combination for the treatment of chronic depression. The New England Journal of Medicine, 342, 1462–1471. https://doi.org/10.1056/NEJM200005183422001

Type of Study: Randomized controlled trial
Number of Participants: 681

Population:

  • Age — Mean=43 years
  • Race/Ethnicity — 90.5% White
  • Gender — 65.3% Female
  • Status — Participants were outpatients recruited from treatment centers.

Location/Institution: Not Specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to compare nefazodone, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or a combination of nefazodone and CBASP. Participants were randomly assigned to receive 12 weeks of CBASP, nefazodone, or a combination of nefazodone and CBASP. Measures utilized include the Hamilton Rating Scale for Depression (HRSD). Results indicate all three groups showed significant pretest to posttest improvement. However, improvement in the combined drug and CBASP group was greatest compared with the nefazodone alone group and the CBASP-only group. Limitations include lack of long-term follow-up, lack of a placebo-only control, and reduced generalizability due to restrictive participant exclusion criteria.

Length of postintervention follow-up: None.

Nemeroff, C. B., Heim, C. M., Thase, M. E., Klein, D. N., Rush, A. J., Schatzberg, A. F., Ninan, P. T., McCullough, J. P., Jr., Weiss, P. M., Dunner, D. L., Rothbaum, B. O., Kornstein, S., Keitner, G., & Keller, M. B. (2003). Differential responses to psychotherapy versus pharmacotherapy with chronic forms of major depression and childhood trauma. Proceedings of the National Academy of Sciences, 100(24), 14293–14296. https://doi.org/10.1073/pnas.2336126100

Type of Study: Randomized controlled trial
Number of Participants: 681

Population:

  • Age — 18–75 years
  • Race/Ethnicity — 90.5% Caucasian
  • Gender — Not Spectified
  • Status — Participants were outpatients recruited from treatment centers.

Location/Institution: Not Specified

Summary: (To include basic study design, measures, results, and notable limitations)
This study used the sample from Keller et al. (2000). The purpose of the study was to examine the effects of treatment responses in chronic depression. Participants were randomly assigned to receive 12 weeks of Cognitive Behavioral Analysis System of Psychotherapy (CBASP), nefazodone, or a combination of nefazodone and CBASP. Measures utilized include the Hamilton Rating Scale for Depression (HRSD) and the Childhood Trauma Scale (CTS). Results indicate a significantly different pattern of treatment response in participants who reported childhood trauma from those who did not. For those who reported no trauma, nefazodone combined with CBASP was significantly superior to either CBASP or drug therapy alone. In comparison, participants with a history of trauma showed a significantly better response to CBASP than to drug therapy, and the combination of drug and CBASP was not better than CBASP alone. Limitations include examination of only one form of psychotherapy and one antidepressant medication and generalizability due to ethnicity.

Length of postintervention follow-up: None.

Manber, R., Arnow, B., Blasey, C., Vivian, D., McCullough, J. P., Blalock, J. A., Klein, D. N., Markowitz, J. C., Riso, L. P., Rothbaum, B., Rush, A. J., Thase, M. E., & Keller M. B. (2003). Patient's therapeutic skill acquisition and response to psychotherapy, alone and in combination with medication. Journal of Psychological Medicine, 33(4), 693–702. https://doi.org/10.1017/S0033291703007608

Type of Study: Randomized controlled trial
Number of Participants: 431

Population:

  • Age — 18-75 years
  • Race/Ethnicity — 91.9% White
  • Gender — 66.4% Female
  • Status — Participants were chronically depressed outpatients recruited from treatment centers.

Location/Institution: Not Specified

Summary: (To include basic study design, measures, results, and notable limitations)
This study used a subsample from Keller et al. (2000). The purpose of this study was to examine the effects of one of three treatments: Cognitive Behavioral Analysis System of Psychotherapy (CBASP), the antidepressant nefazodone, or a combination of the two. Participants were randomly assigned to receive 12 weeks of CBASP, nefazodone, or a combination of drug and CBASP. Measures utilized include the Hamilton Rating Scale for Depression (HRSD) and the Patient Performance Rating Form. Results indicate although reductions in depression were significantly greater in combined treatment compared to CBASP alone, there were no between-group differences in either the rate of skill acquisition or overall skill level at the end of treatment. Proficiency in the use of the main skill taught in psychotherapy at treatment midpoint predicted outcome independently of medication status and of baseline depressive severity. Limitations include results may be specific to the treatments provided, CBASP and nefazodone, and may not generalize to other forms of psychotherapy or to other antidepressant medications; generalizability due to sample, population and ethnicity; lack of follow-up; and may be specific to major depressive disorder only.

Length of postintervention follow-up: None.

Klein, D. N., Santiago, N. J., Vivian, D., Blalock, J. A., Kocsis, J. H., Markowitz, J. C., McCullough, J. P., Jr., Rush, A. J., Trivedi, M. H., Arnow, B. A., Dunner, D. L., Manber, R., Rothbaum, B., Thase, M. E., Keitner, G. I., Miller, I. W., & Keller, M. B. (2004). Cognitive-Behavioral Analysis System of Psychotherapy as a maintenance treatment for chronic depression. Journal of Consulting and Clinical Psychology, 72(4), 681–688. https://doi.org/10.1037/0022-006X.72.4.681

Type of Study: Randomized controlled trial
Number of Participants: 82

Population:

  • Age — Mean=45.1 years
  • Race/Ethnicity — 91.5% White
  • Gender — 67.1% Female and 32.9% Male
  • Status — Participants were outpatients recruited from treatment centers.

Location/Institution: Not Specified

Summary: (To include basic study design, measures, results, and notable limitations)
This study used a subsample from Keller et al. (2000). The purpose of the study was to test the efficacy of psychotherapy as a maintenance treatment. Patients who had responded to their initial 12 weeks treatment in Keller et al. (2000) were randomly assigned to receive monthly maintenance Cognitive Behavioral Analysis System of Psychotherapy (CBASP) or to assessment alone for a further year. Measures utilized include the Hamilton Depression Rating Scale (HRSD) and the Inventory of Depressive Symptoms, Self-Report version (IDS-SR-30). Participants in the CBASP maintenance condition were less likely to experience recurrence of depression than those in the assessment-only condition. CBASP patients also showed a small reduction in symptoms over time, while those in the assessment-only condition showed a small increase. Significantly fewer patients in CBASP experienced a recurrence compared to those in the assessment-only condition. The two conditions also differed significantly on change in depressive symptoms over time. Limitations include sample size, generalizability due to gender and disorder, and reliability of both instruments utilized in study.

Length of postintervention follow-up: None.

Schramm, E., Zobel, I., Dykierek, P., Kech, S., Brakemeier, E. L., Külz, A., & Berger, M. (2011). Cognitive Behavioral Analysis System of Psychotherapy versus Interpersonal Psychotherapy for early-onset chronic depression: A randomized pilot study. Journal of Affective Disorders, 129(1-3), 109–116. https://doi.org/10.1016/j.jad.2010.08.003

Type of Study: Randomized controlled trial
Number of Participants: 30

Population:

  • Age — 18-65 years
  • Race/Ethnicity — Not Specified
  • Gender — Not Specified
  • Status — Participants were patients who met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for a current episode of chronic Major Depressive Disorder (MDD), MDD superimposed on a preexisting dysthymic disorder, recurrent MDD with incomplete remission between episodes in a patient with a current MDD and a total duration of at least 2 years, or dysthymia.

Location/Institution: Department of Psychiatry and Psychotherapy of the University Medical Center Freiburg, Germany

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine patients with early-onset chronic depression. Participants were randomly assigned to Cognitive Behavioral Analysis System of Psychotherapy (CBASP) or Interpersonal Psychotherapy (IPT). Measures utilized include the Hamilton Rating Scale for Depression (HRSD), the Child Trauma Questionnaire, the Structured Clinical Interview for DSM-IV, and the Beck Depression Inventory (BDI). Results indicate there was no significant difference in post-treatment HRSD scores between the CBASP and the IPT condition, but a significant difference was seen on the self-rated BDI scores, with subjects in the CBASP condition reporting a significantly higher reduction in self-rated depressive symptoms. Significantly higher remission rates were found in CBASP as compared to the IPT group. One year posttreatment, no significant differences were found between the two groups in the self-reported symptom level (BDI). Limitations include small sample size which may limit the statistical power of the study.

Length of postintervention follow-up: 12 months.

Klein, D. N., Leon, A. C., Li, C., D'Zurilla, T. J., Black, S. R., Vivian, D., Dowling, F., Arnow, B. A., Manber, R., Markowitz, J. C., & Kocsis, J. H. (2011). Social problem solving and depressive symptoms over time: A randomized clinical trial of Cognitive-Behavioral Analysis System of Psychotherapy, brief supportive psychotherapy, and pharmacotherapy. Journal of Consulting and Clinical Psychology, 79(3), 342-352. https://doi.org/10.1037/a0023208

Type of Study: Randomized controlled trial
Number of Participants: 491

Population:

  • Age — 18–75 years
  • Race/Ethnicity — 85.1% White, 6.1% Other, and 4.3% Black
  • Gender — 42.8% Male
  • Status — Participants were patients who met criteria for major depressive disorder and had achieved less than full remission following treatment with antidepressant medication.

Location/Institution: Eight sites in the US

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine the associations between treatment, social problem solving, and depression in a randomized clinical trial testing the efficacy of psychotherapy augmentation for chronically depressed patients who failed to fully respond to an initial trial of pharmacotherapy. Participants were randomly assigned to Cognitive-Behavioral Analysis System of Psychotherapy (CBASP) plus medication, Brief Supportive Psychotherapy (BSP) plus medication, or medication alone for 12 weeks. Measures utilized include the Social Problem Solving Inventory–Revised and the Hamilton Depression scale. Results indicate CBASP plus pharmacotherapy was associated with significantly greater improvement in social problem solving than BSP plus pharmacotherapy, and a trend for greater improvement in problem solving than pharmacotherapy alone. In addition, change in social problem solving predicted subsequent change in depressive symptoms over time. However, the magnitude of the associations between changes in social problem solving and subsequent depressive symptoms did not differ across treatment conditions. Limitations include a lack of post-intervention follow-up and concerns regarding generalizability, as the study was conducted at academic centers.

Length of postintervention follow-up: None.

Schramm, E., Zobel, I., Schoepf, D., Fangmeier, T., Schnell, K., Walter, H., Drost, S., Schmidt, P., Brakemeier, E., Berger, M., & Normann, C. (2015). Cognitive Behavioral Analysis System of Psychotherapy versus escitalopram in chronic major depression. Psychotherapy and Psychosomatics, 84(4), 227–240. https://doi.org/10.1159/000381957

Type of Study: Randomized controlled trial
Number of Participants: 60

Population:

  • Age — 18-65 years
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were outpatient clients recruited from treatment centers.

Location/Institution: University Medical Centers of Freiburg and Bonn, Germany

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of this study was to compare Cognitive Behavioral Analysis System of Psychotherapy (CBASP) to escitalopram (ESC) for patients with chronic major depression. Participants were randomly assigned to either 22 sessions of CBASP or to escitalopram (ESC) plus 18 sessions of clinical management (ESC/CM) over 28 weeks. Measures utilized include the Montgomery-Asberg Depression Scale (MADRS), the Inventory of Depressive Symptomatology, Self-Report (IDS-SR), the Global Assessment of Functioning scale (GAF), the Social Adaptation Self-Evaluation Scale (SASS), and the Childhood Trauma Questionnaire (CTQ). Results indicate that depression scores decreased significantly after 8 and 28 weeks with no significant differences between the groups. The response rates after 28 weeks of treatment were high, and the remission rates were moderate with neither group being superior. Limitations include small sample size, intervention not superior to comparison group, and lack of follow-up.

Length of postintervention follow-up: None.

Schramm, E., Kriston, L., Zobel, I., Bailer, J., Wambach, K., Backenstrass, M., Philipp Klein, J., Schoepf, D., Schnell, K., Gumz, A., Bausch, P., Fangmeier, T., Meister, R., Berger, M., Hautzinger, M., & Härter, M. (2017). Effect of disorder-specific vs nonspecific psychotherapy for chronic depression: A randomized clinical trial. JAMA Psychiatry, 74(3), 233–242. https://doi.org/10.1001/jamapsychiatry.2016.3880

Type of Study: Randomized controlled trial
Number of Participants: 268

Population:

  • Age — CBASP: Mean=44.7 years; SP: Mean=45.2 years
  • Race/Ethnicity — Not specified
  • Gender — CBASP: 70.1% Female; SP: 61.8% Female
  • Status — Participants were adult outpatients with early-onset chronic depression who were not taking antidepressant medication.

Location/Institution: Eight university centers throughout Germany

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the efficacy of the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) compared with that of nonspecific supportive psychotherapy (SP). Participants were randomly assigned to CBASP or SP. Measures utilized include the Hamilton Rating Scale for Depression (HRSD-24), the Inventory of Depressive Symptomatology (Self-Rated) (IDS-SR), the Global Assessment of Functioning (GAF) scale, the 12-Item Short-Form Health Survey (SF-12), the Quality of Life in Depression Scale (QLDS), and the Childhood Trauma Questionnaire–Short Form. Results indicate the mean baseline HRSD-24 scores of in the CBASP group and in the SP group improved after 20 weeks, with a significant adjusted mean difference in favor of CBASP. Patients undergoing CBASP were more likely to reach response or remission after 20 weeks. Patients undergoing CBASP showed significant advantages in most other secondary outcomes. Limitations include generalizability due to patients being from academic settings, patients were not blinded to their treatment, and small difference between groups regarding clinical baseline data, experience of therapists and noncompliance with protocol.

Length of postintervention follow-up: None.

Bausch, P., Fangmeier, T., Meister, R., Elsaeßer, M., Kriston, L., Klein, J. P., Zobel, I., Hautzinger, M., Härter, M., & Schramm, E. (2020). The impact of childhood maltreatment on long-term outcomes in disorder-specific vs. nonspecific psychotherapy for chronic depression. Journal of Affective Disorders, 272, 152–157. https://doi.org/10.1016/j.jad.2020.03.164

Type of Study: Randomized controlled trial
Number of Participants: 256

Population:

  • Age — 18–65 years
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were adult outpatients who were diagnosed with early onset (before age 21) Major Depressive Disorder (MDD).

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
This study used a subsample from Schramm et al. (2017). The purpose of the study was to analyze follow-up data of extended treatment with Cognitive Behavioral Analysis System of Psychotherapy (CBASP) or Supportive Psychotherapy (SP). Participants were randomly assigned to 24 sessions (20 weeks) of acute and 8 sessions (28 weeks) of extended treatment with CBASP or SP. Measures utilized include the Hamilton Rating Scale for Depression (HRSD), the Childhood Trauma Questionnaire (CTQ-SF), the Structured Clinical Interview for DSM-IV (SCID I and II), and the Longitudinal Interval Follow-Up Evaluation Interview (LIFE). Results indicate the presence of childhood maltreatment (CM) did not significantly moderate long-term effects of CBASP compared to SP. The analysis of trauma subtypes revealed that patients with childhood emotional abuse had statistically significant worse outcomes than patients without and that the advantage of CBASP over SP was larger in patients with childhood emotional abuse than in patients without after 1 year. No significant effects were found for other trauma subtypes. Limitations include the measurement of CM was limited to retrospective self-assessment and data from the same trial has recently been used to test the moderation effect of CM during acute treatment, which may introduce an increased possibility of sample specific results

Length of postintervention follow-up: 1 and 2 years.

Schramm, E., Kriston, L., Elsaesser, M., Fangmeier, T., Meister, R., Bausch, P., Zobel, I., Bailer, J., Wambach, K., Backenstrass, M., Klein, J. P., Schoepf, D., Schnell, K., Gumz, A, Löwe, B., Walter, H., Wolf, M., Domschke, K., Berger, M.,…Härter, M. (2019). Two-year follow-up after treatment with the cognitive behavioral analysis system of psychotherapy versus supportive psychotherapy for early-onset chronic depression. Psychotherapy and Psychosomatics, 88(3), 154–164. https://doi.org/10.1159/000500189

Type of Study: Randomized controlled trial
Number of Participants: 207

Population:

  • Age — CBASP: Mean=44.62 years; SP: Mean=46.47 years
  • Race/Ethnicity — Not specified
  • Gender — CBASP: 72.6% Female; SP: 62.4% Female
  • Status — Participants were outpatients with early-onset chronic major depression.

Location/Institution: Eight university centers throughout Germany

Summary: (To include basic study design, measures, results, and notable limitations)
This study used the sample from Schramm et al. (2017) The purpose of the study was to evaluate the effects of the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) compared to Supportive Psychotherapy (SP). Participants were randomly assigned to either CBASP or SP. Measures utilized include the Longitudinal Interval Follow-Up Evaluation (LIFE), the Hamilton Rating Scale for Depression (HRSD), the Quick Inventory of Depressive Symptomatology (QIDS-C), the Self-Rated Inventory of Depressive Symptomatology (IDS-SR), the Global Assessment of Functioning (GAF), the Short-Form Health Survey (SF-12), and the Quality of Life in Depression Scale (QLDS). Results indicate there was no statistically significant difference between CBASP and SP patients in experiencing well weeks and in remission rates in the 2 years after treatment. Statistically significant effects were found in favor of CBASP 1 year after treatment termination regarding the rate of well weeks, self-rated depressive symptoms, and depression-related quality of life. Limitations include patients were recruited from academic centers only, there was a moderate imbalance between the groups at baseline, and the specific kind and dosage of antidepressant medication as well as possible withdrawal syndromes were not assessed during follow up.

Length of postintervention follow-up: 1 and 2 years.

Additional References

McCullough, Jr., J. P. (2003). Patient's manual for CBASP. Guilford Press.

McCullough, Jr., J. P. (2006). Treating chronic depression with disciplined personal involvement: CBASP. Springer.

McCullough, Jr., J. P. (2003). Treatment for chronic depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Guilford Press. (paperback edition)

Contact Information

James P. McCullough, Jr., PhD
Title: Distinguished Professor of Psychology & Psychiatry
Agency/Affiliation: Virginia Commonwealth University
Department: Department of Psychology
Website: www.cbasp.org
Email:
Phone: (804) 740-7646
Fax: (804) 740-0305

Date Research Evidence Last Reviewed by CEBC: April 2021

Date Program Content Last Reviewed by Program Staff: June 2015

Date Program Originally Loaded onto CEBC: March 2010