Question 1

How is persistent depressive disorder different from episodic/acute major depression?

James P. McCullough, Jr. · Accepted Answer

Episodic/acute major depression (MD) is more often than not precipitated by a crisis event that may be identified. This is not the case with Persistent Depressive Disorder (PDD) – particularly, early-onset PDD. Patients cannot identify the precipitants. Acute MD usually remits after 6-8 months regardless of the treatment administered. Again, this is not the case with PDD. It is a lifetime disorder unless treated successfully. An interesting phenomenon exists among MD patients. As noted above, 80% remit within 6-8 months; however, 20% do not remit, and these patients go on to develop a chronic course (PDD) and may be treated the way other PDD patients are treated. If interested, read my book https://www.amazon.com/Distinctive-Treatment-Persistent-Depressive-Disorder-ebook/dp/B00Q8U47EG.

Question 2

Is much known about the etiology of chronic depression?

James P. McCullough, Jr. · Accepted Answer

Yes. Early onset Persistent Depression Disorder (PDD) usually begins in early adolescence and is accompanied by a very dysfunctional familial environment. Most adolescents do not become depressed unless something highly interpersonally toxic is going on in the home. The individual is faced with a situation where growth and development are precluded, and the child moves into a mode where “survival, not growth” becomes the only coping strategy possible. Late-onset patients (> 21 years) usually are faced with a highly stressful event that precipitates a depressive episode. Interestingly, 20% of these late-onset patients who develop a major depressive episode go on to develop a chronic course. We do not know why. If interested, read my book https://www.amazon.com/Distinctive-Treatment-Persistent-Depressive-Disorder-ebook/dp/B00Q8U47EG.

Question 3

What is CBASP in a nutshell and how does it differ from traditional CBT?

James P. McCullough, Jr. · Accepted Answer

I cannot give you a “nutshell” description of differences. CBASP differs from CBT in every way possible. It is an interpersonal model of psychotherapy. CBASP approaches psychopathology very differently than CBT with very different assumptions. The role of the therapist is totally different and based on a Disciplined Personal Involvement style of behavior. The CBASP model is totally operationalized and is grounded on an acquisition learning approach to patient goals. If you are still interested, read my book (particularly pp. 3-5) https://www.amazon.com/Distinctive-Treatment-Persistent-Depressive-Disorder-ebook/dp/B00Q8U47EG.

Question 4

Can you speak to the difference (if any) in building motivation for change for chronic depression in  youth as compared to adults?

James P. McCullough, Jr. · Accepted Answer

Motivation is the “key” variable in working with PDD patients. The most powerful motivating variable is negative reinforcement. You remember BF Skinner’s definition: Whatever behavior terminates a negative/distressing/painful internal state, functions as a reinforcer. I have found that positive reinforcement strategies are not very influential with chronic depression. Teaching patients how to end their misery with counter-conditioning behaviors will work most of the time. I constantly look for behaviors which help patients feel better. If interested, read my book (pp. 72-75) https://www.amazon.com/Distinctive-Treatment-Persistent-Depressive-Disorder-ebook/dp/B00Q8U47EG.

Question 5

Do you have any advice for working with young adults who are sometimes characterized as "failure to launch" - usually living at their parents home, struggling with depression, engaging in excessive video games and other media?  Thank you.

James P. McCullough, Jr. · Accepted Answer

CBASP has been developed to treat the patient you just described. The motivating variable is the “key” to successful treatment. The most powerful motivating variable is negative reinforcement. You remember BF Skinner’s definition: Whatever behavior terminates a negative/distressing/painful internal state, functions as a reinforcer. I have found that positive reinforcement strategies are not very influential with chronic depression. Teaching patients how to end their misery with counter-conditioning behaviors will work most of the time. I constantly look for behaviors which help patients feel better. If interested, read my book (pp. 72-75) https://www.amazon.com/Distinctive-Treatment-Persistent-Depressive-Disorder-ebook/dp/B00Q8U47EG.

Question 6

I often have clients who have missed / skipped their appointment when they are depressed and not even motivated to come out for the session. How do I motivate them?

James P. McCullough, Jr. · Accepted Answer

CBASP has been developed to treat the patient you just described. I want my patients miserable and feeling terrible. This provides me an opportunity to terminate their aversive internal state which is a negative reinforcement variable motivator. The motivating variable is the “key” to successful treatment. The most powerful motivating variable is negative reinforcement. You remember BF Skinner’s definition: Whatever behavior terminates a negative/distressing/painful internal state, functions as a reinforcer. I have found that positive reinforcement strategies are not very influential with chronic depression. Teaching patients how to end their misery with counter-conditioning behaviors will work most of the time. I constantly look for behaviors which help patients feel better. If interested, read my book (pp. 72-75)
https://www.amazon.com/Distinctive-Treatment-Persistent-Depressive-Disorder-ebook/dp/B00Q8U47EG.

Question 7

If someone has been depressed for 5 or 6 years before attending therapy - this includes staying in bed constantly and hardly eating, what would be the most appropriate step to take at this point to help move him forward?

James P. McCullough, Jr. · Accepted Answer

You are describing an individual who has lost all hope of doing anything to make themselves feel better; in short, they’ve given up, almost. CBASP has been developed to treat the patient you just described. I want my patients miserable and feeling terrible. This provides me an opportunity to terminate the aversive internal state which is a negative reinforcement variable motivator. The motivating variable is the “key” to successful treatment. The most powerful motivating variable is negative reinforcement. You remember BF Skinner’s definition: Whatever behavior terminates a negative/distressing/painful internal state, functions as a reinforcer. I have found that positive reinforcement strategies are not very influential with chronic depression. Teaching patients how to end their misery with counter-conditioning behaviors will work most of the time. I constantly look for behaviors which help patients feel better. If interested, read my book (pp. 72-75) https://www.amazon.com/Distinctive-Treatment-Persistent-Depressive-Disorder-ebook/dp/B00Q8U47EG.

Question 8

I have a client that is developing a chronic alcohol abuse/dependence problem. When challenged he justifies and attributes his behavior to everything and everyone but himself. Redirects and complex reflections aren't effective. Any suggestions?

James P. McCullough, Jr. · Accepted Answer

All of us are full of baloney. This patient is just full of more baloney than most. I don’t have anything to offer you except the Disciplined Personal Involvement Role (DPI) that is part and parcel of CBASP. This patient is what I call a “PRE-THERAPY PATIENT.” They are not ready for psychotherapy that could teach them to behave differently. I do not have the space to describe the DPI role here nor do I have the space to discuss the ‘PRE-THERAPY PATIENT’ and how I use DPI to resolve the impasse. If you are interested in pursuing this topic further and I hope you are, read my book (pp. 48-50) https://www.amazon.com/Distinctive-Treatment-Persistent-Depressive-Disorder-ebook/dp/B00Q8U47EG.

Question 9

I would like to know how to support and communicate with family members of a chronically depressed patient who often feel totally helpless?

James P. McCullough, Jr. · Accepted Answer

I don’t have a lot of contact with the family of Persistently Depressed Disordered patients. Most of my patients are adults, and I see them individually. They are emotive and behavioral trainwrecks and individuals who are not pleasant to be around. Of course, they wreak havoc in their families. Frankly, I want them distressed and hurting which gives me an opportunity to help them terminate their distress which is the most powerful reinforcer you’ve got at your disposal. This provides me an opportunity to terminate their aversive internal state which is a powerful negative reinforcement motivator. The motivating variable is the “key” to successful treatment. The most powerful motivating variable is negative reinforcement. You remember BF Skinner’s definition: Whatever behavior terminates a negative/distressing/painful internal state, functions as a reinforcer. I have found that positive reinforcement strategies are not very influential with chronic depression. Teaching patients how to end their misery with counter-conditioning behaviors will work most of the time. I constantly look for behaviors which help patients feel better. What is nice is that as they begin to change and make progress, much of the familial distress will be mitigated and finally, terminated. If interested, read my book https://www.amazon.com/Distinctive-Treatment-Persistent-Depressive-Disorder-ebook/dp/B00Q8U47EG.

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