The Significant Other History: An Interpersonal-Emotional History Procedure Used with the Early-onset Chronically Depressed Patient

Foreward

The present article introduces the Significant Other History ([SOH], McCullough, 2000, 2006; McCullough, Lord, Conley & Martin, 2010), an interpersonal-emotional history procedure used to guide Cognitive Behavioral Analysis System of Psychotherapy (CBASP) clinicians in their treatment of the chronically depressed patient. While the SOH has been used in two large clinical trials with chronically depressed patients (Keller, McCullough, Klein, Arnow, Dunner, Gelenberg, et al., 2000; Kocsis, Gelenberg, Rothbaum, Klein, Trivedi, Manber, et al., 2009), a formal description of the procedure has not been presented or discussed in detail in psychotherapy journals.

Introduction

The CBASP model of treatment for early-onset chronic depression (DSM-IV, APA, 1994) is essentially a learning-based model of psychotherapy (McCullough et al., 2010), and is the only psychotherapy model developed exclusively for the treatment of chronic depression (McCullough, 2000, 2006). McCullough and others (e.g., McCullough, 2006, 2010; McCullough, et al., 2010; McCullough & Penberthy, 2011) argue elsewhere that early-onset chronic depression is a refractory mood disorder maintained by a longstanding and pervasive pattern of interpersonal avoidance. The avoidance behavior appears to be fueled by felt interpersonal fear that has been widely generalized across persons and situational cues/contexts (Bouton, 2007; McCullough, 2008a; McCullough, et al., 2010; McCullough & Penberthy, 2011). The interpersonal avoidance pattern can be so debilitating that it perceptually disconnects the patient from others. This leaves the person orbiting in a lifetime pattern of repetitive interpersonal sameness. This childlike egocentric-pattern, where the person is not informed by his or her interactions with others is labeled, preoperational functioning (McCullough, 2000, 2006; McCullough et al., 2010; McCullough & Penberthy, 2011; Piaget, 1923/26; Wilbertz, Brakemeier, Zobel, Harter & Schramm, 2010; Zobel, Werden, Linster, Dykierek, Drieling, Berger, et al., 2010). Preoperational functioning has been described in detail elsewhere (McCullough, 2000, 2006; McCullough et al., 2010) and has been investigated under the labels Theory of Mind (ToM) and mentalization (e.g., Inoue, Tonooka, Yamada, & Kanaba, 2004; Inoue, Yamada, & Kanaba, 2006; Wilbertz et al, 2010; Zobel et al., 2010; Schnell, Bluschke, Konradt & Walter, 2011). Both constructs, ToM and mentalization, describe the mental ability to infer another’s beliefs, affective states, or intentions as one aspect of psychological maturity. This inter-personal capacity requires that the individual be able to “stand outside” him- or herself perceptually (a formal operational thought capability) and view another within a non-egocentric social context. In short, ToM and mentalization require empathic capabilities, a mental capacity that early-onset chronic patients do not possess.

Psychological Insults and Trauma

The interpersonal fear noted above more often than not appears to stem from a long-standing developmental history of either (a) psychological insults and/or (b) trauma (McCullough, 2006, 2008a; McCullough, et al., 2010) received at the hands of maltreating caregivers or Significant Others (SOs). Cowan (1978) and others (Cicchetti & Barnett, 1991; Guidano & Liotti, 1983; Hammen, 1992; Hammen, Burge, Daley, Davila, Paley & Rudolph, 1995) suggest that the entire emotional universe of the child is centered on the early attachment he or she achieves with his or her caregivers, particularly the mother. These early attachment relationships influence the infant’s interests toward the environment, feelings of respect for others, general interpersonal feelings toward others and the ambient emotional tone that permeates all cognitive constructions. An aversive developmental-attachment environment, filled with years of psychological rejection from maltreating caregivers, demeaning comments or emotional neglect, is often a characteristic feature of early-onset chronic depression. These conditions may not satisfy a more traditional definition of trauma; however, like traumatic events, they contribute to the exacerbation of the early-onset disorder (Cicchetti & Barnett, 1991; Cicchetti & Toth, 1998; Hammen, 1992). It is for this reason that we have coined the term, psychological insult as being one contributory factor in the onset of childhood/adolescent chronic depression. The authors (McCullough, 2008a; McCullough, et al., 2010) define psychological insult as a continuous series of experiences, encountered by the developing child or adolescent, that are associated with interpersonal punishment/rejection and are of a ‘low grade’ nature; in contrast, trauma signifies one or more life threatening or ‘high grade’ dangers the individual experiences (e.g., sexual and/or physical abuse, actual parental abandonment, emotional or physical neglect: McCullough, 2008a; Nemeroff, Heim, Thase, Klein, Rush, Schatzberg, et al., 2003; Wiersma, Hovens, van Oppen, Giltay, van Schaik, Beekman, et al., 2009).

Goals of SOH

The Significant Other History, a CBASP procedure administered during session two of treatment, samples the interpersonal-emotional history of the early-onset patient focusing on his or her experiences with SOs (McCullough, 2000, 2006; McCullough, et al., 2010; McCullough & Penberthy, 2011). The SOH is administered to achieve three goals:

Clarification of the Circularity, Two-Person Assumption in Interpersonal Theory as it Pertains to Early-Onset Chronic Depression

The Cognitive Behavioral Analysis System of Psychotherapy is described in the literature as an interpersonal model of psychotherapy (McCullough, 1984, 2006, 2008b; McCullough, 2010; McCullough, et al., 2010; McCullough & Penberthy, 2011). As noted above, many early-onset chronically depressed patients are perceptually disengaged from others (i.e., their social environment) in informing ways. Several labels have been proposed for this phenomenon such as “rigidity” (Wachtel, 1973), “indiscriminant responding” (Mischel, 1973), and “consistent behavior across situations” (Moos, 1968; as summarized by Kiesler, 1996, p. 196). These labels aptly describe chronically depressed patients as they consistently behave in an interpersonally rigid and indiscriminant manner, regardless of persons or situations. This interpersonal style is best characterized as “interpersonal sameness.”

It is the chronically ill patient’s functional sameness that exposes the issue we must clarify. Interpersonal theory assumes, a priori, that person-to-person transactions involve bidirectional circularity (Kiesler, 1996). Kiesler writes: “Interpersonal transactions consist of two-person mutual influence. Causality is simultaneously bi-directional; it is circular (Danziger, 1976) rather than linear” (Kiesler, 1996, p. 5).¹

The two-person mutual influence model is illustrated below with the arrows indicating the directions of interactional flow:

The patient with early-onset chronic depression does not function in a circular interpersonal way when treatment begins (McCullough 2000, 2006). Given the pervasiveness of interpersonal avoidance, intra-personal not inter-personal functioning best describes the untreated chronic patient. Through his Maladaptive Transaction Cycle, Kiesler (1985, 1986, 1988; 1996, pp. 194-197) attempts to address the patient’s lack of circularity by demonstrating how metacommunicative feedback can be administered to a dysthymic (chronic) patient. Metacommunication is a verbal interpersonal feedback strategy that communicates how the patient’s behavioral impact is affecting the clinician (e.g., “When you do this, you make me feel like. . . .”). His conceptualization of the psychopathology of dysthymia and its treatment derives from Coyne’s (1976) interactive model for depression, which suggests that depression is largely an interactional problem. Chronic depression is more than simply an interactive dilemma, and it is not modifiable by corrective interpersonal feedback alone. At the beginning of treatment, the patient with early-onset chronic depression does not behave in a two-person manner. Therefore, the circularity assumption of interpersonal theory does not adequately describe the patient’s idiosyncratic functioning (Leary, 1955, 1957; Leary & Coffey, 1954; Kiesler, 1982, 1988, 1996; Sullivan 1953a, b). The patient’s one-person functioning dilemma is illustrated below: Note that the psychotherapist’s behavior does not penetrate the wall of interpersonal fear at the beginning of treatment:

Simply put, it is difficult to adhere to an interpersonal view of psychotherapy with a patient who is not influenced in a circular or bi-directional way and who is entrapped behind a refractory wall of interpersonal fear. Thus, the essential work of the CBASP clinician is to teach patients to behave interpersonally.

Felt Safety

The CBASP model has been designed specifically to open the “circularity” loop the patient has kept closed for many years by breaking through the patient’s wall of interpersonal fear and establishing a zone of felt safety. This felt safety must be established so that intra-personal functioning can be counter-conditioned with dyadic reciprocity (McCullough, et al., 2010). Successfully establishing interpersonal safety prepares the way for the patient to master the next step, which is, learning to function interpersonally and to generate empathy, important steps to acquire before patients can break out of their refractory intra-personal isolation. Once felt safety is established in the therapeutic dyad, patient behavior can assume a circular and/or bi-directional causal capability. The SOH will play a central role in this change process. In the sections to follow, we will demonstrate how the SOH provides essential information the practitioner can proactively utilize to jump-start the opening process.

Returning to the major aim of the paper, we now describe how the origins of the core interpersonal fear are identified in the SOH, how CBASP practitioners construct the TH using the causal theory material and lastly, how clinicians administer the TH to teach patients to function interpersonally and to generate empathy.

Clarifying the Origins of the Core Interpersonal Fear

Representative Early Abuse Material Available from Recent Research

Before describing the SOH procedure, it may be helpful to readers for us to illustrate some typical psychological insult/trauma histories taken from a representative sample of patients with early-onset chronic depression. These histories are drawn from Elisabeth Schramm’s personal files transcribed during a recent study of early-onset chronically depressed patients. The project (Schramm, Zobel, Dykierek, Kech, Brakemeier, Kültz et al.’s, 2011) was completed recently in Freiburg, Germany and compared the treatment efficacy of CBASP to that of Interpersonal Psychotherapy ([IPT] Klerman, Weissman, Rounsaville & Chevron, 1984). The 30 early-onset patients received 22 sessions of psychotherapy and 15 patients with early-onset chronic depression were randomized to each treatment cell. The researchers defined early trauma as an experience of emotional/physical/sexual abuse or emotional/physical neglect before age 18 years and a score in the moderate-to-severe range on the Childhood Trauma Questionnaire ([CTQ] Bernstein, Fink, Handelsman, Foote, Lovejoy, Wenzel et al., 1994). Seventy-nine percent in the Schramm et al. sample met criteria as early trauma subjects. Emotional neglect and abuse were the modal categories endorsed on the CTQ followed by physical neglect and sexual and physical abuse. E. Schramm (2011) randomly generated a list of 4 patients from her early-trauma group to illustrate the typical developmental histories of this cohort. All of the 4 subjects produced CTQ trauma scores in the severe-to-extreme range.

• Patient 1 was a 21-year-old female reporting extreme sexual and physical abuse (beatings) from ages 5 years to 11 years by her stepfather. She reported that he screamed at her and threw her favorite stuffed animals in the trash. She recalled him saying to her: “I will be your first sexual partner as soon as you turn 12.” She also reported that her mother never protected her from her stepfather.

• Patient 2 was a 28-year-old female who experienced severe-to-extreme emotional neglect and abuse coupled with physical and sexual abuse. The patient recalled that her mother often took the patient on dates in a car while the mother had sex with her male friends.

• Patient 3 was a 42-year-old female with a history of severe-to-extreme physical and emotional abuse as well as neglect. As a young child the patient worked hard on the family farm and was often physically beaten by her father. She described her life as one in which she had never known a “decent” human being.

• Patient 4 was a 54-year-old female who reported severe-to-extreme sexual and emotional abuse and neglect. The patient’s mother made it clear that she never wanted her, and she ignored and ridiculed the patient throughout the time the patient remained at home. The patient also reported a history of her biological father sexually abusing her.

When developing children are overwhelmed by the dangers of an abusive or neglectful home life, normal development is thwarted because the children’s energies and behaviors are not directed towards growth but towards surviving the “hell of the family” (Drotar & Sturm, 1991; Money, 1992; Money, Annecillo, & Hutchinson, 1985). McCullough (2000, 2006) writes that among many adult early-onset patients a failure to mature cognitively and emotionally is often painfully evident in the way the patients talk and behave.

The first author recently treated a preoperational patient who presented with a destructive developmental history similar to the four cases described above. The following conversation took place during an early session and provides an example of the primitive verbal style and behavior clinicians often confront with early onset patients:

• Patient : The company photographer didn’t take my picture at the company picnic. He took Susan, Jane, and Mary’s pictures but not mine. He didn’t take my picture because he didn’t like me.

• JPM : Did you know this man previously and did you ask him to take your picture?

• Patient : No, I didn’t know him, and I didn’t ask him to take my picture. It wouldn’t have mattered. He wouldn’t have done it because he doesn’t like me.

• JPM : How do you know he doesn’t like you?

• Patient : I just know it. I just believe he doesn’t. Nobody likes me.

Reviewing the four abbreviated abuse histories and this example conversation between a therapist and patient make it easier to understand why early-onset chronically depressed individuals present with a pervasive interpersonal fear of others. These fears result in a generalized, interpersonal avoidance pattern that acts to maintain the preoperational, intrapersonal functioning of the chronically depressed adult. We turn our attention now to a description of the SOH procedure.

The Significant Other History Procedure

At the end of session one, the patient is asked to bring a list of up to six Significant Others (SOs) to the next session. The SOs are carefully defined as the people around whom the patient grew up or with whom he or she currently interacts. All of these major players have significantly influenced the direction the patient’s life has taken as these are the individuals who have left their emotional stamp or mark on the person. In short, a SO denotes a person who has exerted either a positive or negative influence on the way one lives, thinks and feels. Patients are then instructed that during the next session the list will be reviewed with two goals in mind: (1) to recall several memories (with associated affect) to obtain a description of what it was like growing up or being around each SO; (2) to pinpoint the emotional stamp or mark the patient bears today because of each SO’s influence. In CBASP the “stamps” are labeled causal theory conclusions (McCullough, 2000, 2006) denoting their influence on the patient’s current life. Cognitive Behavioral Analysis System of Psychotherapy clinicians usually write the SOH material on a large flip chart or dry erase board in full view of the patient.

Common Challenges in Administering the SOH

Administering the SOH will be the first time the clinician asks the preoperational patient to think abstractly; that is, requests the individual to take a step back perceptually and to form causal theory conclusions about the stamps/marks he or she bears from several SOs. Some patients have difficulty completing this abstractive step and have to be assisted to construct these conclusions. Others respond in a vague manner and are unable to deduce any conclusions; in these cases, the clinician must infer the causal theory conclusions from the history. The procedural format of the SOH is shown below in Table 1.

As stated earlier, the exercise is essentially an interpersonal-emotional history procedure because of the way the SOH highlights the patient’s learning history. Patients frequently describe previous therapy experiences in which they were asked to “talk about” their pasts as well as discuss important persons in their lives. Such techniques inadvertently position the patient in an observer role when they talk about their SOs. Not infrequently, these individuals will say that they experience little or no emotional reaction when talking about the past. However, organizing one’s personal history in a SOH format positions the patient in a participant role. The patient describes specific hurtful experiences perpetrated by specific SOs and the consequences or influences they bear from these relationships. The SOH exercise often evokes significant emotional arousal that ranges from moderate-to-extreme felt discomfort. Since the procedure is done early in therapy (session 2), when many patients have not yet learned to trust the therapist, a retraumatization experience cannot always be avoided. Part of the pervasive avoidance style of the patient has included not recalling painful memories. The SOH may exacerbate painful associations that are connected to specific memories. The clinician must end the SOH exercise by discussing the explicit material written on the flip chart (e.g., “What is it like for you to see all this information written on the flip-chart?”) and then address any discomforting affect that may be present.

Finally, it must be noted that the SOH is primarily administered for the benefit of the clinician. That is, the information gleaned from the SOH will clarify and help define the therapist’s role with a patient by providing relevant information about the nature of the interpersonal fear the person brings to treatment. The history may also alert the practitioner to potential “relational pitfalls” that lay ahead and that, when wisely avoided, prevent the individual from prematurely leaving treatment. For example, a male therapist may assume that a friendly and helpful interpersonal demeanor is an effective therapeutic stance; however, with a female who presents with a sexual abuse history where her stepfather was always friendly and helpful prior to making sexual advances, the SOH will prevent the clinician from unquestionably relying on this interpersonal style.

Soh and the Autobiographical History Research Tradition

The SOH procedure clearly falls within the purview of the autobiographical memory (AM) research literature (Conway & Pleydell-Pearce, 2000; Williams, Barnhofer, Crane, Hermans, Raes, Watkins et al. 2006; Williams, Barnhofer, Crane & Beck, 2005). However, there are some notable differences between the procedure and goals of the SOH and the experimental elicitation procedures and goals involved in AM studies. First, in SOH it is the experienced emotional affect of the associated memory that is of primary importance, not the quality of the recalled memory. Secondly, the SOH is a clinical exercise used to access information solely for the construction of a transference hypothesis, which allows for future interpersonal discrimination between the psychotherapist and the maltreating significant others. Finally, the SOH has been studied only within the context of CBASP treatment for chronically depressed patients.

Soh and An Illustrative Case History

A case history of a 43-year-old female, Anne, is briefly presented below to illustrate the kind of SO material and the causal theory conclusions that are evoked in the SOH exercise.

Case

Anne was diagnosed “double depression” (Keller, Lavori, Endicott, Coryell & Klerman, 1983) and reported a dysthymia onset around age 13 years. She had not received previous treatment and described a 30-year history of depression with a minimum of 3 to 4 major depressive episodes. Most remarkable was her psychological insult and trauma history. When she was 10, her father died after a lengthy illness and her mother remarried while Anne was still in elementary school. The step-father was alcoholic and Anne’s mother worked at a full-time job. While Anne’s mother was at work, the step-father physically abused Anne, beating her with a belt whenever she disobeyed the house rules, and he often forced the child (from ages 11 to 16) to have sex with him. Anne never told her mother of the abuse nor did Anne know if her mother knew or suspected the abuse. “To escape” from the family, Anne married at age 17. Her husband was also alcoholic and physically abusive. She divorced him two years later.

The patient completed high school and has remained unmarried. She has worked for the past 20 years as a cashier in a pharmacy. Her Significant Other list included: Mother, Biological father, Step-father, Husband.

Mother: Emotionally distant, made me feel unlovable; she was always working. Mother rarely prepared meals, and most of the time, I had to fix my own meals as well as do the grocery shopping. She and my step-father often yelled and fought with each other, but the conflicts never became physical. Mother left me alone and I stayed in my room a lot when she was home.

Causal Theory Conclusion: I am an unlovable person.

Biological-Father: I remember him always being sick. He had a serious cancer and stayed in bed most of my childhood. I rarely talked to him but remember him being in a lot of pain. I tried to fix his food but he never ate what I fixed. He never thanked me for trying to help him.

Causal Theory Conclusion: I am not much help when people need it.

Step-Father: He hurt me in many ways. He hated me. He sexually abused me for several years [11 years to 16 years old] and would beat me with a belt whenever I disobeyed. He called me a “whore” and “slut” when I was in high school and started dating.

Causal Theory Conclusion: Men will hurt me if I give them the chance.

Husband: He was an alcoholic, physically abusive and “a loser.” I married him thinking that I would be able to get away from the hell of my family. Anne said: “Lot of good getting married did. I walked right into another nightmare. I divorced my husband two years later.”

Causal Theory Conclusion: I’m afraid of men, they will hurt me.

The interpersonal-emotional THEMES that run through Anne’s SOH causal theory conclusions are as follows:

Therapist’s note concerning this TH: Patient’s fear of males has been well learned; thus, I predict that Anne expects nothing positive to come out of our relationship.

Next, we describe the process of Transference Hypothesis construction and discuss some of the issues that are associated with TH construction.

Constructing the Transference Hypothesis: Targeting the Salient Transference Domain that Best Fits the Sources of the Interpersonal Fear

The Four Interpersonal Domains

There are four frequently-occurring dyadic interactional domains in psychotherapy that can be used “to anchor” the Transference Hypothesis.

These interactional domains take place between most therapists and patients and include the following (examples of Casual Theory Conclusions appear after each domain):

Causal Theory Conclusion: “I must always smile and put on a happy face or else face rejection or censure.”

Not surprisingly, these in-session interpersonal events or domains often implicate/parallel the reported sources of pain/injury revealed in the SOH. This point will become clearer as we proceed. Following session two, the clinician selects the one interpersonal domain that is most reflective of the salient theme/motif running through the causal theory conclusions. For example, in the case of Anne, the therapist selected the intimacy/relationship domain in which to anchor the TH by deducing the salient theme/motif from the causal theory conclusions, and selecting the most appropriate TH hot spot, (i.e. one of the four domain-specific interpersonal targets).

The TH must meet two criteria,

The Transference Hypothesis Must be Stated in a Functional Manner

The TH is always stated in an “if this. . ., then that. . .” sentence. The sentence implies that if the patient engages in one of the domain-specific behaviors, the expected consequence (based on previous learning) will pull some hurtful/painful response from the practitioner. Ethical codes for “professional behavior” dictate against psychotherapists reacting in adverse ways; however, the patient’s emotional system does not always react in ways that adhere to expectations concerning professional behavior. Instead, interpersonal-emotional fears are activated by discrete stimulus cues whenever they occur in common exchanges between clinicians and their patients. These dyadic stimulus fear cues are labeled hot spots and occur when, for example, an intimacy/relationship TH is implicated. The TH helps practitioners recognize these sometimes subtle stimulus cues when they occur in the session. During moments of dyadic shared intimacy, hot spots can take a number of forms. For example, a hot spot is revealed whenever the patient shares an event never-before related, which signals a personal disclosure TH, while a patient forgetting an appointment denotes a lack-of-perfection behavior for one whose TH makes explicit that punishment always follows making a mistake; and lastly, the TH hot spot concerning expressing negative emotion is exposed when the “always smiling patient” becomes overtly frustrated or angry with her therapist.

Common Problems and Issues in TH Construction

Problem 1

Some patients after only two sessions do not provide sufficient information for TH construction. The first author (JPM) has worked with patients whose causal theory conclusions do not result in a clearly defined TH by the end of session two. For example, it took five sessions with one 55-year-old male patient before a relevant TH hypothesis became apparent. The following TH was initially settled on because it expressed a long-standing interpersonal fear in the patient’s life:

Problem 2

The TH is a hypothesis and it can be modified or changed if the practitioner decides that it does not adequately describe the core interpersonal fear. While not a frequent occurrence, this problem does occur and when it does, the TH should be modified to more adequately reflect the patient’s fear. Beginning CBASP practitioners often need assistance in pinpointing the central core fear domain for the TH.

Problem 3

Clinicians must take their gender into account in TH construction, particularly in cases where sexual abuse is reported. A psychotherapist whose gender is the same as the malevolent SO who perpetrated the abuse is likely to evoke a greater fear response than one whose gender differs from the perpetrator.

Problem 4

Lastly, the TH helps practitioners gain better control over their negative emotional responses toward patients (e.g., frustration and hostility). Making the patient’s core interpersonal fears explicit in the TH construction provides the clinician with information with which to understand the patient’s avoidance responses that naturally evoke frustration and felt hostility on the part of practitioners—especially during periods of no change. Understanding the reason for another’s behavior often mitigates knee-jerk adverse reactions that occur when understanding is absent.

The Transference Construct: CBASP & Psychoanalytic Theory

Despite the overlap in terminology, there are some notable distinctions between the generation and utilization of the SOH-informed TH used in CBASP and the use of transference interpretations in psychodynamic psychotherapy (e.g., Høglend, Bøgwald, Amlø, Marble, Ulberg, Sjaastad et el., 2008; Høgland, 2004). Høgland (2004) and Høgland et al. (2008) describe how analytic therapists consider the patient’s historical material and offer a transference interpretation to illuminate the motivation behind some current maladaptive behavior. In one study, Høglend et al. (2008) investigated the efficacy of transference interpretations on a wide variety of psychiatric disorder groups and reported no treatment outcome differences between patients who received transference interpretations and those who did not; however, the authors found that patients who received transference interpretations sustained better relationships on the outside during the four-year period of the study. These articles are important because they demonstrate the use of the transference construct in a widely known psychotherapy model and because they offer us a good yardstick to compare the distinctive use of the construct in CBASP. As noted, several differences exist between CBASP and psychodynamic psychotherapy in transference generation and utilization in treatment. The differences are the following:

Using the SOH to Prepare the Way for Teaching One-Person Functioning Patients to Generate Empathy

Anne’s SOH presented previously makes explicit the learned interpersonal fears she brings to treatment. Her fears resulted from maltreatment experiences with SOs and have motivated her to live out a refractory pattern of interpersonal avoidance. Anne is also typical of many early onset chronic patients who are interpersonally closed off from any two-person or circular/reciprocal-deterministic interactions (Kiesler, 1996; Bandura, 1977). The treatment conceptualization question the practitioner must answer is the following: What does Anne have to learn that will “open” the circular interpersonal loop so that her therapist as well as others may inform her behavior? (McCullough et al. 2010).

Over repeated in-session trials, the patient (in this example, Anne) must learn three things: (1) the therapist, Dr. Howard, will not hurt or reject her in any way. In short, Anne must acquire a feeling of felt safety with Dr. Howard as she successfully discriminates him from maltreating SOs; (2) Anne must generalize her felt safety feelings with one or two (or more)

individuals outside of the therapeutic dyad. The in-session gains must be enacted with other social contacts; and (3) that Anne must learn that in reality she is not interpersonally helpless at all. Rather, she can learn to produce the interpersonal outcomes she wants with others. It is hypothesized that the successful acquisition of these learning goals will resolve the chronic depressive disorder (McCullough, et al. 2010).

The Interpersonal Discrimination Exercise

The SOH plays a significant role by helping the patient open the circularity loop first with the psychotherapist and then with others. Anne’s TH is stated once again: If I have a relationship with Dr. Howard, then he will hurt me/reject me in some way. The TH will be activated any time the dyad encounters a relationship issue during the session, signaling that a relational “hot spot” has been encountered (e.g., working together on a task in therapy; talking together about a sensitive personal matter; sharing moments of obvious experienced closeness; etc.). The Interpersonal Discrimination Exercise is then administered (McCullough, 2000, 2006; McCullough & Penberthy, 2011; McCullough, et al., 2010). The IDE administration procedure is shown in Table 2.

The goal of IDE administration is to shape up the patient’s ability to make clear discriminations between the practitioner and her hurtful SOs. The discrimination exercise, administered only once per session, will have the therapist ask the patient to compare and contrast what it was like when she got close to her SOs and what it is like now when she achieves relational closeness with the therapist. In addition, she will also be asked to verbalize the hurt, pain, and fear associated with closeness to the SOs versus the absence of hurt, pain, and fear and the presence of felt safety when closeness is achieved with the therapist. Therapists never achieve adequate discriminations in a few sessions. However, over time and across many in-session encounters where hurt and pain are absent and felt safety is present, patients gradually learn that the therapist is qualitatively different than the SOs who hurt them. During this process, intra-personal functioning and the wall of fear is penetrated, and the “circularity loop” is progressively opened. Being able to perceive the therapist as “different” appears to dissipate the fear. Interpersonal functioning between practitioner and patient now becomes possible, new learning becomes achievable, and patients begin to use language to make themselves understood and to understand the clinician. This characteristic of interpersonal functioning reflects Piaget’s concept of empathy, which denotes a mature, socialized type of language exchange (Piaget, 1923/1926).

Acquisition Learning of Authentic Interpersonal Functioning

It was important that Anne learn what her psychotherapist sought to teach. One thing she learned was to self-administer the 4-step IDE exercise to criterion. First, she mastered pinpointing how her SOs reacted to her in a specific relational-domain context (i.e. relational intimacy was the “hot spot” TH domain). Next, Anne increased her ability to describe the behavior of her clinician as he reacted to her in the same transference-fear domain (i.e. relational intimacy moments). Third, she learned, with progressive clarity, to compare and contrast the interpersonal differences between the SOs THEN and Dr. Howard’s behavior NOW and to discriminate the experienced affect differences (e.g., This was the way I felt THEN, this is the way I feel NOW.). Finally, as Anne came to believe that

she would not be hurt by Dr. Howard, she was increasingly able to identify new interpersonal possibilities open to her.

Assessment of Learning Performance

Anne’s therapist rated her in-session IDE performance using the Form for Scoring the Self-Administered Interpersonal Discrimination Exercise ([SAd-IDE] McCullough, et al. 2010). Anne’s IDE acquisition-performance learning curve, reflected in her SAd-IDE scores along with her self-reported felt safety ratings over 30 sessions, are illustrated in Figure 1.

The safety ratings were anchored on a 5-point Likert scale: 1 (feel very safe with the therapist), 2 (feel moderately safe), 3 (not sure how I feel), 4 (feel moderately unsafe) and 5 (feel very unsafe).

Anne reached IDE mastery criterion (McCullough, et al. 2010) during the 27^th session, indicating that she self-administered the IDE twice in succession (i.e. during sessions 26^th and 27^th) with no step errors. Figure 1 also shows the relationship between her IDE performance scores and her self-reported feelings of felt safety with the therapist. The data support a hypothesized dependent relationship between the learning variable (IDE performance scores) and the emotional variable (felt safety scores). Achieving felt-safety was a significant accomplishment for Anne - the process was slow and cumulative.

Conclusions

In summary, patients with early-onset chronic depression who enter treatment unable to function in a two-person manner can learn to function interpersonally and to generate empathy in the therapy dyad (and beyond) if the core fear state is counter-conditioned and replaced with felt safety. The SOH is the procedure used to identify the locus of the interpersonal fears and to provide the content for the TH. Using the TH, the CBASP clinician then begins to teach patients over repeated trials to self-administer the IDE to discriminate between the hurtful behavior of their SOs compared and contrasted to the behavior of the therapist. When patients achieve felt safety within the dyad, learning is enhanced and patients are assisted to counter-condition the avoidance lifestyle replacing it with an interpersonal-approach style of living.

The Limitations of the Soh Proposal

At this point, there are several limitations in this proposal that must be mentioned. There are no data that address the specific contributions that the Interpersonal Discrimination Exercise (IDE) and Situational Analysis (SA) make to the overall effectiveness of CBASP to resolve the patient’s generalized interpersonal avoidance and perceptual disconnection from the environment—the two major treatment goals of CBASP (McCullough et al. 2010).

Stated more specifically, dismantling studies of CBASP are important for future research with the model (McCullough, 2006; McCullough et al., 2010). Formal studies dismantling the specific contributions of the components of CBASP, which seek to compare the SA and IDE separately and in combination, must be undertaken. However, we have replicated intensive design data suggesting that the SOH and IDE exercises increase felt safety of early-onset chronic patients and conversely, decrease their interpersonal fear of the psychotherapist (McCullough, 2005, 2008b; McCullough & Penberthy, 2011; McCullough et al. 2010; as well as the actual case presented in this paper).

Discussing the utility of the SOH when it is employed by other therapeutic models is beyond the scope of the paper. To the authors’ knowledge, the SOH, in the form described herein, has never been used with any other program of treatment. The SOH exercise is taught to all training CBASP clinicians who see patients under the tutelage of CBASP Supervisors. Further information about CBASP training activities may be obtained by going to the CBASP Website: www.cbasp.org.