Cognitive behavioural analysis system of psychotherapy

1. Introduction

Version followed: McCullough's individual CBASP (Treatment for Chronic Depression, 2000; Skills Training Manual, 2001) as taught in current CBASP Society training handouts (Penberthy, University of Virginia), with German/Swiss inpatient and group adaptations (Brakemeier, Schramm, Guhn) named where used. The 2000 and 2001 manuals themselves are not drawn on; their procedures are reconstructed from training handouts by McCullough's collaborators and from the manuals' published tables of contents [uncertain where noted].

CBASP is an individual psychotherapy built by James P. McCullough Jr. (Virginia Commonwealth University) specifically for persistent (chronic) depression, especially early-onset forms. It combines behavioural, cognitive, interpersonal and psychodynamic-style ideas with Piaget's developmental theory [source: Wikipedia; CBASP Basics; Schramm et al. 2019].

Core idea of change: the chronically depressed person is described as functioning, in social situations, like Piaget's preoperational child: egocentric, talking in monologue, with global thinking and little sense that their behaviour affects others. Early maltreatment or later wearing stressors produce fear of others (Pavlovian) and pervasive avoidance (Skinnerian), so relationships become one-way and hopelessness is kept alive. Change comes through two routes: (1) a new, safe relationship with a therapist who is deliberately and personally involved (Disciplined Personal Involvement), which builds felt safety; and (2) repeated, structured analysis of real interpersonal situations (Situational Analysis), which builds formal-operational thinking and "perceived functionality", the felt knowledge that what one does makes a difference to outcomes [source: McCullough 2018 workshop slides; CBASP Basics; Penberthy handouts]. Behaviour is understood as a function of person × environment (B = f(P×E)) [source: Penberthy handouts].

2. Framework

CBASP is defined by three required components: the Significant Other History with transference hypothesis, Situational Analysis with the Coping Survey Questionnaire (CSQ), and Disciplined Personal Involvement (Interpersonal Discrimination Exercise plus Contingent Personal Responsivity). Without all three, a treatment should not be called CBASP [source: CBASP Basics].

Treatment goals (training version): felt emotional safety with others; social problem solving at a formal-operational level; empathic responsiveness in social situations ("interpersonal mindfulness") [source: CBASP Basics]. Wikipedia's summary lists four goals: connect patients to their interpersonal world, teach mood control, teach effective negotiation of relationships, and maintain gains through ongoing practice [source: Wikipedia].

Implementation sequence: diagnosis → SOH, causal theory conclusions and transference hypothesis → SA with CSQ → DPI (IDE and CPR) → transfer and generalisation → added skills training if needed → outcome [source: CBASP Basics].

Phase A: Assessment (pre-treatment, 1–2 sessions)

Goals: confirm persistent depressive disorder and comorbidity, with attention to the course of illness over time; rate severity; judge suitability; introduce CBASP and give the Patient's Manual; ask the patient to list 3–5 significant people (names only, without overthinking) [source: Penberthy handouts].
McCullough's skills manual has a dedicated chapter on diagnosing with a Clinical Course Timeline [source: Guilford contents, 2001 manual]; procedure details in §4 are partly [synthesis].
Move on when: diagnosis is established, the patient agrees to the structured format and has a list of significant others.

Phase B: Initial sessions (about sessions 1–3)

Goals: explain the rationale; take the Significant Other History; derive causal theory conclusions; formulate (usually one) transference hypothesis, which may or may not be shared with the patient; the therapist completes the Impact Message Inventory (IMI) on their own reactions to the patient [source: Penberthy handouts; CBASP Basics].
Move on when: SOH completed and transference hypothesis written; CSQ introduced. SA starts by the third session [source: CBASP Basics].

Phase C: Middle / active phase (the bulk; "20+ sessions" in the training handouts)

Goals: teach SA with the CSQ, one event per session (past or future); review the IMI for the patient's "stimulus value" and likely interpersonal hot spots; use IDE whenever a transference hot spot arises and CPR whenever the patient's behaviour has an impact on the therapist; continuously assess acquisition (can they do SA?) and discrimination learning (can they tell therapist from maltreating others?) [source: Penberthy handouts].
Progression within the phase: the therapist does much of the prompting early; later the patient completes SAs alone in session and forms realistic desired outcomes on their own, which is taken as evidence of transfer and perceived functionality [source: Penberthy handouts]. The relationship shifts from the therapist acting unilaterally as the patient's "environment" to a more mutual, reciprocal relationship [source: Penberthy handouts].

Phase D: Termination

Criterion: the patient self-administers SA correctly to criterion as rated on the Patient Performance Rating Form (PPRF), and symptoms and functioning are significantly improved, ideally remitted [source: Penberthy handouts]. The exact PPRF cut-off was not found [uncertain]. McCullough's 2000 manual has a chapter on measuring skill acquisition and generalised treatment effects [source: Guilford contents, 2000 manual].

Phase E: Maintenance

Booster sessions at widening intervals or as needed, on the rationale that relapse follows loss of learning [source: Penberthy handouts]. In the German inpatient model a roughly 4-week "fresh-up" stay is offered about 6 months after discharge [source: Brakemeier et al. 2014].

Typical session count and format (name the version you follow)

Original US trial (Keller et al. 2000): 12-week acute treatment; commonly reported as 16–20 sessions with twice-weekly sessions early [uncertain].
German multicentre RCT (Schramm et al. 2017, follow-up 2019): 32 sessions over 48 weeks: 24 acute sessions over 16 weeks, then 8 continuation sessions over 28 weeks [source: Schramm et al. 2019].
Inpatient multimodal CBASP (Charité Berlin): 12 weeks, 2 individual sessions plus 2 manualised group sessions per week (a 100-minute SA group and a 60-minute Kiesler Circle Training group), weekly supervision [source: Guhn et al. 2021]. Freiburg CBASP@5: 10–12 weeks in three phases (about 2 weeks introduction, main phase, about 2 weeks farewell) [source: Brakemeier et al. 2014].
Group formats: 4–10 patients, 1–2 sessions per week of 90–120 minutes, at least 10 sessions, semi-open [source: Brakemeier et al. 2014].
Session length for individual outpatient CBASP was not stated in the sources; a standard 50-minute session is assumed [uncertain].

3. Guiding principles

Person × environment (B = f(P×E)). Always tie the patient's behaviour to its consequences in the environment, including the therapist. Practical meaning: every SA and CPR ends with the patient seeing the link between what they did and what they got [source: Penberthy handouts].
Perceived functionality is the target. The aim is for the patient to feel that their actions change outcomes. Practical meaning: judge progress by whether the patient can explain why they did or did not get their desired outcome, not only by mood scores [source: McCullough 2018 slides].
Felt safety comes first. The therapist is a "new" attachment-type figure who will not hurt the patient. Practical meaning: protect the relationship deliberately; when a hot spot arises, slow down and make the safety explicit via IDE [source: McCullough 2018 slides; CBASP Basics].
Disciplined Personal Involvement (DPI). A proactive, planned use of the therapist's own reactions (a "countertransference role"), not neutrality and not unplanned self-disclosure. Practical meaning: you show your reactions on purpose, for the patient's learning, guided by the transference hypothesis and the IMI [source: McCullough 2018 slides; CBASP Basics].
Therapist as unilateral environment early, mutual partner later. Practical meaning: early on do not react like an ordinary social partner (for example by withdrawing when the patient is curt); shape your reactions as teaching consequences; let the relationship become reciprocal as the patient gains skills [source: Penberthy handouts].
Situational, not global. Practical meaning: always pull vague, general complaints ("my life is hopeless") down to one concrete, time-limited situation with a beginning and an end [source: McCullough 2018 slides; CBASP Basics].
Piagetian "mismatching". Ask questions slightly above the patient's current level (stepping back, perspective taking, cause and effect) rather than accepting egocentric monologue. Practical meaning: keep asking the patient to reason, rather than reasoning for them [source: Penberthy handouts].
The patient does the work. Practical meaning: the patient revises outcomes, summarises learning and generalises; the therapist prompts, does not supply answers or advice, and uses motivational-interviewing-style questions when a goal is unrealistic [source: CBASP Basics; Penberthy handouts].
Goals must be in the patient's control. A desired outcome must be behavioural, realistic (the patient can produce it) and attainable (the environment can deliver it). Practical meaning: never accept "I wanted him to apologise" as a final DO [source: Penberthy handouts].
Approach instead of avoidance. Fear plus avoidance keeps emotion "frozen"; change needs contact with the feared interpersonal context. Practical meaning: use in-session hot spots rather than steering around them [source: Penberthy handouts; Wikipedia].
Consequences made explicit. Practical meaning: name the impact of the patient's behaviour on you openly and specifically, then pinpoint an alternative [source: CBASP Basics].
Use the patient's own words. Practical meaning: write their interpretations and outcomes verbatim and check you have them right [source: Penberthy handouts].
One event, done thoroughly. Practical meaning: one SA per session in the active phase; do not skip steps [source: Penberthy handouts].
Generalisation is built in. Practical meaning: every SA ends with "where else does this apply?" and later SAs are run prospectively for upcoming situations [source: CBASP Basics].
Relief strengthens learning (negative reinforcement). McCullough's motivational strategy is usually summarised as letting the patient experience relief of distress when they discover what they could do differently [uncertain: from the 2000 manual's motivation chapter].

4. Intervention inventory

Order follows the CBASP implementation sequence. Interventions 1–12 are core McCullough CBASP; 13–18 are adaptations or optional add-ons, marked as such.

1. Diagnosis and Clinical Course Timeline

Purpose / when: Pre-treatment. Establish persistent depression (early vs late onset, single chronic episode vs depression layered on dysthymia, incomplete recoveries) and comorbidity; the course pattern shapes the formulation and expectations [source: Penberthy handouts; Guilford contents, 2001 manual, ch. 3].
Steps: (1) Draw a horizontal time line from childhood or first symptoms to today. (2) Ask the patient to mark when low mood began, worst periods, periods of feeling well and how long they lasted. (3) Mark treatments, losses and major interpersonal events on the line. (4) Classify the course (onset age, any full recovery, layering of episodes). (5) Rate current severity with a standard depression scale. (6) Share the picture with the patient as the problem CBASP targets. [synthesis: step detail reconstructed]
Example language (illustrative): "Let's draw your mood over the years on this line, so we can both see how long this has been going on and whether there were times you felt like yourself."
Watch for: Patients who cannot recall a time of being well (suggests early onset; prepare for longer treatment). Working when the patient recognises the long course as a treatable pattern rather than personal failure [synthesis].

2. Orientation and Patient's Manual

Purpose / when: End of assessment and first session; socialise the patient to a structured, skills-based therapy.
Steps: (1) Give McCullough's Patient's Manual (Guilford, 2003) and ask the patient to read it. (2) In the next session review it and answer questions. (3) Explain the two main tasks: looking at important people from the past, and analysing one recent stressful interaction each session. (4) Ask the patient to list 3–5 significant people, names only [source: Penberthy handouts].
Example language (illustrative): "This therapy is quite structured. Most sessions we will take one specific situation from your week and work out, step by step, what you wanted, what happened and what you could do differently."
Watch for: Over-long lists or detailed stories at this stage; keep it to names. Hopeless predictions that it won't work: note them as material for later SA rather than debating them [synthesis].

3. Significant Other History (SOH) and causal theory conclusions

Purpose / when: Sessions 1–2. Make explicit the tacit learning the patient took from formative relationships; this feeds the transference hypothesis [source: McCullough 2018 slides; CBASP Basics].
Steps: (1) Explain why: we want to see how important people left their "stamp". (2) Use the list (5–6 people, positive and negative; if more than 6–7, the patient picks the 5 most influential), in the order the patient gave. (3) For each person start with what it was like growing up with or being around them. (4) Follow with one of: how has this person influenced who you are now; how did growing up with them shape the direction of your life; what kind of person are you because of them. (5) Keep in mind four realms: closeness/intimacy, failure/mistakes, emotional need, and expressing negative feelings. (6) Help the patient phrase one causal theory conclusion per person in the form "Because [what they did], I learned [belief/expectation]". (7) Write the conclusions down in the patient's words [source: Penberthy handouts; CBASP Basics]. Note that asking for these conclusions is itself a mismatching exercise: the patient has to step back and reason about influence [source: Penberthy handouts]. A CBASP Interpersonal Questionnaire (CIQ) is also used in this phase in some training [source: CBASP Basics; item content not seen].
Example language (illustrative): "What was it like growing up around your father?" ... "If you step back from those memories, what did living with him teach you about what happens when you need something?"
Watch for: Long, detached narration with no conclusion (keep asking for the "stamp"); emotional flooding with abuse memories (slow down, ground, keep focus on conclusions rather than full trauma detail) [synthesis]. Working when the patient can state a clear cause-and-effect conclusion.

4. Transference hypothesis (TH)

Purpose / when: Immediately after the SOH. Predict the interpersonal "hot spot" in which the patient will expect the therapist to respond like a harmful significant other; it guides IDE for the whole therapy [source: CBASP Basics; Penberthy handouts].
Steps: (1) Look across the causal theory conclusions for the main theme of fear or pain. (2) Assign it to one of four domains: closeness/intimacy with the therapist; disclosing needs or private material; making mistakes; expressing negative feelings toward the therapist [source: McCullough 2018 slides; Penberthy handouts]. (3) Write it as an if–then: "If I [do X in this domain] with [therapist], then [therapist] will [feared response]." (4) Prefer one primary hypothesis so it gets thorough coverage (training worksheets allow more if the primary one is targeted). (5) Decide whether to share it with the patient [source: Penberthy handouts].
Example (illustrative TH): "If I tell my therapist I made a mistake with the homework, she will be disgusted with me."
Watch for: Hypotheses that are too general ("people hurt me"); keep them tied to the therapy relationship and one domain. Confirmation comes when the predicted hot spot shows up in session [synthesis].

5. Impact Message Inventory (IMI) and stimulus value

Purpose / when: Early sessions, repeated as needed. Identify the patient's interpersonal "stimulus value" (the pull they exert on others) and the therapist's likely unhelpful complementary response, so DPI can be planned [source: CBASP Basics; Penberthy handouts].
Steps: (1) After about the second session the therapist completes Kiesler's IMI on their own reactions to the patient (do not reproduce or alter items; use the licensed form). (2) Graph the scores on the interpersonal circle. (3) Note the peak octants. (4) For each, write: the patient's problem behaviour; your likely reaction; the likely reaction of people outside therapy. (5) Plan a more productive, non-complementary stance [source: Penberthy handouts; CBASP Basics]. Example pattern from the training case: a hostile, curt, avoidant patient pulls the therapist toward distance or hostility; a hostile-submissive patient voicing hopelessness pulls the therapist to take charge; a submissive patient who never voices needs pulls the therapist to take control [source: Penberthy handouts].
Example language (internal note, illustrative): "I notice I'm starting to make all the decisions in session; that is her pull toward submissiveness. Next time I'll wait and ask her to choose."
Watch for: Acting out the pull (lecturing, rescuing, withdrawing). Exactly which stance McCullough prescribes for each octant was not found [uncertain]; the general rule from interpersonal theory is not to complement maladaptive pulls [synthesis].

6. Situational Analysis: Elicitation phase (with the CSQ)

Purpose / when: From session 3 (or earlier) to the end; the mainstay of CBASP. Teaches the patient to see a single interaction concretely and to link interpretations and behaviour to outcomes [source: CBASP Basics; McCullough 2018 slides].
Homework set-up: Between sessions the patient completes the Coping Survey Questionnaire (McCullough's form) on one stressful interpersonal event from the past week; it is reviewed in the next session [source: CBASP Basics; Penberthy handouts].
Steps:
1. Situation: "Describe it like a scene in a film": who said or did what, with a clear start and a clear end point. No commentary, no back-story [source: CBASP Basics; Penberthy handouts].
2. Interpretations: what the event meant to the patient; one sentence each, usually up to three; ask "did it mean anything else?" [source: CBASP Basics; Penberthy handouts].
3. Behaviour: what the patient did, including words, tone of voice, eye contact and posture; in German adaptations also place it on the Kiesler circle [source: CBASP Basics; Brakemeier et al. 2014].
4. Actual Outcome (AO): one observable sentence describing how it ended (the end point from step 1) [source: Penberthy handouts].
5. Desired Outcome (DO): one observable sentence about what the patient wanted; must be realistic and attainable and within the patient's control [source: Penberthy handouts].
6. Comparison: did the patient get what they wanted (AO = DO)? yes or no.
7. Why or why not? [source: CBASP Basics; Penberthy handouts]
Example language (illustrative): "Start where it began and stop where it ended, as if I were watching a video." ... "What did that moment mean to you? ... One sentence." ... "What exactly did you say, and how did you look while saying it?" ... "How did it end, in a way a camera could record?" ... "And what did you want to happen?" ... "Did you get it?"
Watch for: Global summaries instead of a situation (narrow to one time slice); interpretations that are really feelings or behaviour (re-ask for meaning); AOs and DOs about the other person's inner state ("I wanted her to understand"). Early SAs can take the whole session; later the patient moves faster [source: Dustin MacDonald overview; synthesis].

7. Situational Analysis: Remediation phase

Purpose / when: Same session, after elicitation. The patient revises interpretations and behaviour so the DO becomes reachable, sees the link to mood, summarises and generalises [source: CBASP Basics; Penberthy handouts].
Steps:
1. Revise the DO first if needed: if unrealistic (the patient can't produce it) or unattainable (the environment won't deliver it), help the patient conclude this themselves, MI-style, then ask what realistic first step they could want instead [source: Penberthy handouts].
2. Check each interpretation in turn against four questions: relevant to this situation? accurate (describes what happened, not mind reading)? anchored in the present event (not past or future)? helpful for reaching the DO? Revise, drop or add [source: Penberthy handouts; Brakemeier et al. 2014].
3. Add an action interpretation: a short self-instruction that prompts assertive action toward the DO (German adaptations call these "battle cries") [source: Penberthy handouts; Brakemeier et al. 2014].
4. Behaviour: ask how behaviour would change with the new interpretations and whether that would have produced the DO; rehearse with role-play if needed [source: Penberthy handouts]. The aim is productive dissonance: the patient sees their interpretations drove their behaviour and that changed behaviour changes outcome and mood [source: CBASP Basics].
5. Wrap-up: the patient (not the therapist) summarises what they learned and why the DO was or was not reached [source: CBASP Basics].
6. Generalisation: the patient names other similar situations where the learning applies [source: CBASP Basics; Penberthy handouts].
Example language (illustrative): "Was that read about him rooted in what actually happened in the kitchen, or in what you expected?" ... "Did that thought help you get what you wanted?" ... "What could you tell yourself in that moment that would push you to act?" ... "Put it in your own words: what did you learn from this one?" ... "Where else in your life does this come up?"
Watch for: Therapist doing the revising; patient agreeing passively. Working when the patient spontaneously flags an irrelevant or mind-reading interpretation, writes realistic DOs without help and reports relief as they see what they could do [source: Penberthy handouts; synthesis].

8. Prospective (future) Situational Analysis

Purpose / when: Middle and late phase, and whenever a feared event is coming (a talk with a boss, a family visit). Builds transfer [source: CBASP Basics; Penberthy handouts].
Steps: (1) Define a behavioural DO the patient can produce. (2) Identify the interpretations needed, ideally one repeatable action interpretation. (3) Identify the behaviours needed and rehearse by role-play. (4) Skip the AO (it hasn't happened). (5) Keep it simple; review how it went at the start of the next session, which can become a standard SA [source: Penberthy handouts].
Example language (illustrative): "On Thursday, what do you want to have done by the end of that conversation, something you yourself can make happen?"
Watch for: DOs that depend on the other person's reaction; over-planning that becomes avoidance. Working when the patient returns having tried the plan, whatever the outcome [synthesis].

9. Behavioural rehearsal / role-play with shaping

Purpose / when: Within remediation (step 4) and prospective SA, when the patient doesn't know how to perform the new behaviour or performs it submissively [source: Penberthy handouts; Brakemeier et al. 2014].
Steps: (1) Set the scene from the SA. (2) Therapist plays the other person; patient tries the new behaviour. (3) Give positive feedback first, then one specific refinement, including body language, tone and eye contact. (4) Repeat, shaping step by step. (5) Optionally swap roles so the patient experiences the impact [source: Brakemeier et al. 2014; step 5 synthesis].
Example language (illustrative): "That was clear. Now try it once more and keep looking at me while you ask."
Watch for: Freezing or tearfulness (slow down, reduce difficulty); overly hostile assertiveness (place it on the Kiesler circle and adjust toward friendly-dominant) [synthesis].

10. Interpersonal Discrimination Exercise (IDE)

Purpose / when: Any time the in-session interaction enters the domain of the transference hypothesis (a hot spot): for example the patient discloses a need, admits a mistake, gets close, or expresses anger at the therapist. Goal: the patient discriminates the therapist from maltreating significant others and experiences felt safety in the feared context [source: McCullough 2018 slides; CBASP Basics; Penberthy handouts].
Steps: (1) Notice the hot spot as it happens; the in-session event must mirror the original harmful context. (2) Ask how the significant other(s) reacted when the patient did this. (3) Ask how the therapist has just reacted in this same area. (4) Ask what is different between those reactions. (5) Ask what it would mean for the patient if the therapist really does respond differently here (new learning, new possibilities). (6) Over time, extend to supportive people outside therapy and teach the patient to run IDE for themselves [source: Penberthy handouts; CBASP Basics].
Example language (illustrative): "You just told me you didn't do the questionnaire. When you admitted a mistake at home, what did your mother do?" ... "And what did I just do?" ... "What's the difference?" ... "If that difference is real, what does it mean for you here?"
Watch for: The patient discounting the difference ("you're paid to be nice"); answer by staying concrete about observable reactions. Working when the patient notices the difference spontaneously, shows visible relief, or takes more interpersonal risks with you [source: Penberthy handouts; synthesis].

11. Trauma-adapted IDE (comorbid PTSD or trauma focus)

Purpose / when: When DPI targets a specific trauma event and its "impact conclusion" (themes such as safety, trust, power and control, closeness, self-esteem), or both the TH and trauma together, considered most relevant [source: CBASP Basics].
Steps: (1) Identify a hot spot from an SA and its domain (closeness, mistakes, neediness, negative affect). (2) Recall: what did the significant other do, say and look like in a similar situation? (3) Compare: what did the patient do, look like and say, and how did the therapist respond now? (4) New learning: what did the patient learn and what does it mean for future situations? [source: CBASP Basics]
Example language (illustrative): "When you were angry as a child, what did his face look like? ... What does my face look like now?"
Watch for: Dissociation or flooding; keep the focus on contrast and present safety rather than detailed trauma narrative. For full trauma processing, longer or trauma-focused augmentation is used in the German model [source: Brakemeier et al. 2014; synthesis].

12. Contingent Personal Responsivity (CPR)

Purpose / when: Whenever the patient's in-session behaviour has an impact on the therapist (withdrawal, curtness, helplessness, hostility, or new adaptive behaviour). Teaches that the patient's actions have consequences for others (P×E), modifies interfering behaviour and transfers skills [source: CBASP Basics; Penberthy handouts].
Steps: (1) Pinpoint: state your own reaction openly. (2) Identify: name the specific patient behaviour that produced it. (3) Connect: make the P×E link explicit by asking whether the patient realised that what they did affects how you feel now. (4) Pinpoint a more adaptive alternative. (5) Give ongoing feedback as the patient tries it, again making consequences explicit, including positive consequences for adaptive behaviour [source: Penberthy handouts; CBASP Basics].
Example language: Brakemeier et al. quote a therapist saying "Wenn Sie sich so wortlos zurückziehen, merke ich, dass ich mir Sorgen mache" ("When you withdraw without a word like this, I notice I get worried"), then asking what the patient would like from the therapist [source: Brakemeier et al. 2014]. Illustrative: "When you answered 'I don't know' to every question just now, I felt shut out and started doing all the work. Did you notice that what you did had that effect on me?"
Watch for: Disclosure that is punitive or about the therapist's own needs (DPI must stay disciplined and for the patient's learning); shame responses. Working when the patient begins to notice their effect on you before you name it [source: CBASP Basics; synthesis].

13. Kiesler circle analysis with the patient (adaptation)

Purpose / when: German/Swiss CBASP teaches the interpersonal circle directly to patients and uses it in SA step 3. Shows that behaviour is complementary and that the patient often invites the very reactions they fear [source: Brakemeier et al. 2014; Guhn et al. 2021].
Steps: (1) Draw the circle: horizontal axis distant/hostile (left) to close/friendly (right); vertical axis dominant (top) to submissive (bottom). (2) Locate the patient's behaviour in the SA on the circle. (3) Ask what reaction it invites from the other person. (4) Validate the pattern by linking it to the SOH. (5) Ask whether the patient wants to keep that effect or try a friendlier or more assertive behaviour. (6) Rehearse [source: Brakemeier et al. 2014].
Example language (illustrative): "Your silence and turning away sits here, distant and submissive. What does that usually pull from other people? ... Given what you learned at home, that makes sense. Do you want to keep getting that reaction?"
Watch for: Using the circle to label or blame; keep the validating step [source: Brakemeier et al. 2014].

14. Kiesler Circle Training group (adaptation)

Purpose / when: Inpatient/day-clinic group, 60 minutes, half-open, to practise interpersonal behaviour [source: Guhn et al. 2021].
Steps: Modules chosen by group relevance, not fixed order: getting to know the circle; non-verbal communication; verbal communication; conflict training; empathy and corrective interpersonal experiences. Mix brief psychoeducation with experiential exercises, handouts and worksheets [source: Guhn et al. 2021].
Example language (illustrative): "Let's each say the same sentence once from the top of the circle and once from the bottom, and notice how differently it lands."
Watch for: Submissive members not participating; integrate rather than force them [source: Guhn et al. 2021].

15. Situational Analysis group (adaptation)

Purpose / when: Group delivery of SA, 90–120 minutes, 3–10 patients, semi-open, ideally alongside individual CBASP [source: Brakemeier et al. 2014; Guhn et al. 2021].
Steps: One patient's SA per round. Elicitation as usual, with the behaviour placed on the Kiesler circle; group members propose alternative behaviours and the patient chooses one; remediation with interpretation revision and action interpretations; role-play with shaping, peers giving positive feedback first; take-home message; generalisation. If the situation happened on the ward, ask the people involved what they experienced [source: Brakemeier et al. 2014; Guhn et al. 2021].
Example language (illustrative): "Before we suggest anything, who can say what they liked about how Maria handled it?"
Watch for: Overlong SAs and weak cohesion; prepare patients in individual sessions, including their fears about the group and a personal group goal [source: Guhn et al. 2021].

16. Empathy training (adaptation)

Purpose / when: Group module targeting perspective taking (the preoperational deficit) [source: Brakemeier et al. 2014].
Steps: Two therapists role-play an interaction between two people; a third freezes the scene at key moments and asks the observers what each actor is feeling, thinking and will do next; discuss, then resume [source: Brakemeier et al. 2014].
Example language (illustrative): "Stop there. What do you think she is feeling right now? What will she do next?"
Watch for: Patients answering only from their own perspective; gently ask for the other person's view [synthesis].

17. Additional skills training as needed

Purpose / when: When SA shows a skill deficit that SA alone does not fix: assertiveness, coping with urges (e.g. substance comorbidity), problem solving, social and interpersonal skills [source: CBASP Basics; Brakemeier et al. 2014].
Steps: Teach the skill briefly, then practise it inside a prospective SA and role-play so it stays tied to a concrete DO [synthesis]. Specific skill protocols are not prescribed in the sources [uncertain].
Example language (illustrative): "Your DO keeps getting stuck at the moment you need to say no. Let's practise just that part."
Watch for: Drifting into generic CBT; keep it in service of SA goals [synthesis].

18. Mindfulness, self-compassion and modular interpersonal groups (adaptation)

Purpose / when: Optional add-ons in Swiss/German programmes: relational mindfulness and self-care (drawn from MBCT), and an 8-session interpersonal group covering basic skills on the Kiesler circle; conflict (mini-SAs, deep listening); role changes and losses (acceptance vs change, weighing gains and losses); workplace stress (graded "no", asking for help, handling bullying, work–life balance) [source: Brakemeier et al. 2014].
Steps / language / watch for: Follow the local programme manual; these modules are not part of McCullough's core CBASP [source: Brakemeier et al. 2014].

19. Performance rating (PPRF) and termination

Purpose / when: Throughout and at the end, to judge acquisition learning and decide on ending [source: Penberthy handouts].
Steps: (1) Rate each SA on the Patient Performance Rating Form. (2) Track the shift from therapist-prompted to self-administered SAs. (3) End acute treatment when the patient self-administers SA to criterion and symptoms are much improved or remitted. (4) Review the course timeline and SOH conclusions to show change [source: Penberthy handouts; step 4 synthesis].
Example language (illustrative): "Today you went through the whole analysis on your own. That's what we were aiming for."
Watch for: Symptom remission without SA mastery (risk of relapse) [source: Penberthy handouts rationale; synthesis].

20. Booster / maintenance sessions

Purpose / when: After the acute phase, to keep learning intact and prevent relapse [source: Penberthy handouts]. The German RCT used 8 continuation sessions over 28 weeks [source: Schramm et al. 2019].
Steps: Space sessions out; at each, run an SA (often prospective) and check generalisation [synthesis].
Example language (illustrative): "Bring a situation from the last month where you used your analysis, and one that's coming up."
Watch for: Re-emerging avoidance or global thinking; increase frequency. Schramm et al. note CBASP's advantage was lost by year two when therapy could not continue beyond 48 weeks, supporting continued boosters [source: Schramm et al. 2019].

5. Handling problems

McCullough's 2000 manual has chapters on therapists' difficulties with chronically depressed patients, on enhancing motivation, and on common patient problems and crises [source: Guilford contents, 2000 manual], but those chapters are not drawn on [uncertain]. Guidance below is tagged by origin.

Global, hopeless talk instead of a situation. Treat it as the expected preoperational style, not resistance. Acknowledge briefly, then ask for one recent moment with a start and an end; if none comes, ask for the last 10 minutes before the session [source: principle of situational focus, McCullough 2018 slides; specific moves synthesis].
Homework (CSQ) not done. This is often a TH hot spot (mistakes). Run an IDE on it ("what happened at home when you didn't do what was asked; what did I just do?"), then complete the CSQ together in session [synthesis built on the IDE procedure].
Unrealistic or other-controlled desired outcomes recurring. Don't argue; ask whether the patient can produce that outcome themselves, MI-style, until they revise it; then look for a first step [source: Penberthy handouts].
Passivity, helplessness, "I don't know"; therapist pulled to take over. Recognise the submissive pull from the IMI; do not rescue. Use CPR: name your reaction and the behaviour, link them, and wait for the patient to answer or choose [source: Penberthy handouts; CBASP Basics].
Hostility, curtness, avoiding eye contact. Recognise the pull toward distance or counter-hostility. Name the behaviour on the Kiesler circle, validate it by linking to formative experiences, and invite a different behaviour; use CPR to show its impact on you [source: Brakemeier et al. 2014; Penberthy handouts].
Rupture or anger at the therapist. Expressing negative affect toward the therapist is one of the four TH domains, so a rupture is a key IDE opportunity: respond non-punitively, then ask how significant others reacted to such anger and how you are reacting now [source: TH domains, McCullough 2018 slides; rupture handling synthesis].
Emotional overwhelm (grief, trauma memories) during SOH or IDE. Slow down, ground in the present relationship, focus on contrasts and conclusions rather than full trauma narrative; consider trauma-focused augmentation for comorbid PTSD [source: Brakemeier et al. 2014; synthesis].
Feeling worse early in treatment. Expect it: in the Freiburg inpatient follow-up, 56% reported subjective worsening, understood as grief as patients gave up avoidance and saw how formative experiences shaped their lives; it did not predict poor response. Normalise it and keep the structure [source: Brakemeier et al. 2014].
Suicidality and crises. Follow standard risk assessment and safety planning (including lethal-means counselling: storing or removing means); acute suicidality is not an automatic contraindication when the patient can agree to a safety plan, with higher levels of care if needed [source: Brakemeier et al. 2014; risk-assessment detail synthesis]. A crisis can be handled as an SA of the precipitating interaction once the patient is safe [synthesis].
SA becomes rote (patient fills steps but nothing changes). Check whether the action interpretation is being used and whether behaviour was rehearsed; move to prospective SA and role-play; review PPRF ratings with the patient [synthesis].
Patient discounts the IDE ("you are just being professional"). Stay with observable facts of your response; ask what would count as evidence; repeat IDE across many hot spots rather than seeking one conversion [synthesis].
Therapist discomfort with self-disclosure. DPI is deliberate and limited to reactions useful for the patient's learning; plan disclosures from the IMI and TH, and use supervision [source: CBASP Basics; supervision practice from Guhn et al. 2021; synthesis].
Group problems. Time limits, low cohesion, group size and long SA rounds were reported; prepare patients individually, set group rules, integrate submissive members without forcing, and use SA and the circle for in-group conflict [source: Guhn et al. 2021].
Poor fit. Sources list severe psychotic or autistic symptoms and antisocial personality disorder as contraindications for the inpatient programme, recommend DBT first for borderline personality disorder, and note poorer benefit with very high severity, many prior admissions and multiple personality disorders [source: Brakemeier et al. 2014].

Sources

Sources:

Further reading (not drawn on): the 2018 workshop handouts; BMC Psychiatry 2008 CBASP protocol; Keller et al. 2000 abstract.

Books cited:

McCullough, J. P. (2000). Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Guilford Press.
McCullough, J. P. (2001). Skills Training Manual for Diagnosing and Treating Chronic Depression: CBASP. Guilford Press.
McCullough, J. P. (2003). Patient's Manual for CBASP. Guilford Press.
McCullough, J. P. (2006). Treating Chronic Depression with Disciplined Personal Involvement: CBASP. Springer.
McCullough, J. P., Schramm, E., & Penberthy, J. K. (2015). CBASP as a Distinctive Treatment for Persistent Depressive Disorder. Routledge.
Keller, M. B., McCullough, J. P., et al. (2000). A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. New England Journal of Medicine, 342, 1462–1470.
Kiesler, D. J. (1996). Contemporary Interpersonal Theory and Research. Wiley (Impact Message Inventory and interpersonal circle; cited via CBASP Basics).

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