CONTEMPORARY PSYCHOLOGY:
PsycCRITIQUES - August 15, 2007, Vol. 52, Release 33, Article 60

Making Yourself Vulnerable When Treating Chronically
Depressed Clients

Reviewed by: Lawrence P. Riso, PhD

Beginning psychotherapists often feel anxious, vulnerable, and unsure of the impact they are having on their patients. After countless hours of training and practice, most are able to feel steady on their feet and reach a level of comfort in their work. James P. McCullough's latest book, Treating Chronic Depression With Disciplined Personal Involvement: Cognitive Behavioral Analysis System of Psychotherapy, however, has the potential to bring one back to those early days of uncertainty. Incorporating “disciplined personal involvement” into one's work can again make one feel anxious, vulnerable, and as though one was conducting psychotherapy for the very first time. This is because McCullough advocates an intense relationship between therapist and patient that he believes may be critical to the treatment of chronically depressed individuals.

The types of therapist self-disclosures in McCullough's disciplined personal involvement are far deeper than simply sharing one's background and experiences. Rather, his approach involves sharing moment-to-moment personal emotional reactions such as feelings of guilt, anger, frustration, concern, closeness, and shame. The disclosures are intended to be both blunt and immediate. The personal involvement is “disciplined” in that the self-disclosures are carefully timed and choreographed so that they counteract the patient's negative interpersonal expectations with a maximum therapeutic impact. McCullough argues that personal involvement has been discouraged and is even “taboo” in virtually every other major form of psychotherapy. For instance, in classic psychoanalytic psychotherapy, he argues, personal involvement was seen as interfering with the patient's access to unconscious material. In Rogerian therapy, therapists accept, reflect, and validate all aspects of the client's behavior to help the client integrate, evaluate, and self-correct areas of psychological dysfunction. Therapists must resist interjecting their personal reactions so as not to interfere with the self-actualization process. However, according to McCullough, this is an overly narrow role for the therapist that affords limited opportunity for true learning to take place. Moreover, he believes the Rogerian approach unrealistically expects therapists to maintain neutrality in the face of maladaptive interpersonal behavior during session.

In cognitive therapy, the therapist is a neutral and objective
observer of the patient's negative assumptions and behaviors and must “resist all countertransference reactions” that could interfere with this role. McCullough rejects traditional cognitive therapy for chronic depression as being overly rational, non-contextual, and relying too much on internal structures rather than interpersonal behavior. Despite these assertions, however, there are parallels between McCullough's approach and at least some tenets of cognitive therapy. For instance, the emotionally activating personal involvement of McCullough's approach is similar to the notion of “schema activation” in cognitive therapy (Ingram, Miranda, & Segal, 1998) and to the emotive techniques used in schema focused cognitive therapy (see, e.g., Young, Klosko, & Weishaar, 2003).

In reviewing other forms of psychotherapy, McCullough sees little or no role for the therapist's personal emotional reactions. Ruptures in the therapeutic alliance are dealt with by focusing on the patient's maladaptive patterns of thinking and behavior rather than using the therapist's personal reactions. Providing patients with blunt feedback as to the impact of their behavior is one of the most powerful interventions at a therapist's disposal yet is severely underused. There are some theorists who McCullough believes have focused on the therapist's reactions and whom he credits with influencing his approach. Most notable among them is Donald Kiesler (1991, 1996), who developed an interpersonal circumplex model that McCullough has incorporated into his therapy. Although not discussed in the book, there may also be some elements of McCullough's approach in dialectical behavior therapy (DBT; Linehan, 1993). For instance, DBT encourages the expression of the natural responses of the therapist in session (known as “radical genuineness”). Moreover, DBT encourages clients to make efforts to repair the relationship with therapists as problems in the alliance arise. McCullough criticizes the “Herculean” effort that most therapies require to maintain therapist neutrality in the face of dysfunctional interpersonal behavior by patients during session. However, the balance of bold personal disclosure and restraint required of McCullough's disciplined personal involvement may also require personal qualities and interpersonal skill that are just as unique.

To his credit, McCullough does address some of the difficulties in applying disciplined personal involvement. He notes that some therapists find disciplined personal involvement uniquely challenging, are concerned about blurring the boundaries of the therapeutic relationship, and believe the approach can be overwhelming for patients. McCullough writes that one therapist remarked, “I could literally feel myself sweat when I expressed personal feelings because I feared creating something I wouldn't be able to handle” (p. 69). Another therapist expressed a fear of “allowing myself to experience discomfort during the session” (p. 69).

Accordingly, McCullough concedes that his approach is “simply not for everyone” (p. 53). The deeply personal nature of the disclosures in disciplined personal involvement is revealed in the book's extensive case material. One therapist was confronted by a patient who became frustrated and angry at being asked to stick to one topic during sessions. The therapist responded by saying, “I have to solve everything at once or else I'm a failure—which means I cannot help you. You've had me over a barrel, and I've been feeling very frustrated—I can't win with you” (p. 64). In an exchange with a self-deprecating patient, the therapist remarked, “Your comments about how bad you are. They make me feel totally helpless to do anything; they leave me without any energy” (p. 94). Another therapist dealt with a highly critical patient by asking, “Why did you just berate me in anger? I want to know.” The patient responded, “Did I hurt your feelings?” to which the therapist replied, “Yes, you did… Why would you do this to me?” (p. 67).

Positive disclosures are also part of disciplined personal
involvement. After a very productive exchange, one therapist remarked, “I'm amazed at all the discoveries you've made about us. We'll keep working on these issues and see how far you can take them. I want to sit here for a moment and enjoy what's just happened between us” (p. 52). Disciplined personal involvement makes use of blunt, raw, genuine disclosures from the therapist that are emotionally evocative for the patient. They are used to strategically counteract the patient's destructive interpersonal assumptions. In McCullough's
words, the therapist's job is to become “a problem for the patient” (McCullough, 2000, p. 264). That is, patients should have difficulty incorporating therapists' genuine expressions of caring and concern (for both their patient's well-being and their relationship with them) into the negative expectations they harbor from past negative interactions. The therapist's honesty, genuineness, and persistence make it difficult for the patient to escape these awkward interactions using the distancing strategies (counterattacking or withdrawing) he or she tends to use with others. In this way, the patient is thus forced to reconcile the therapist's facilitative behavior with his or her negative expectations. After several such interactions, the hope is that the patient will resolve this contradiction by altering his or her view of relationships. Patients are guided to draw a sharp distinction between the caring and forthright behavior of the therapist and the destructive behavior of significant others in their past using the “interpersonal discrimination exercise.” The exercise involves four steps: (a) pinpointing the situation that triggered the patient's negative expectations of the therapist, (b) asking patients to recall how others reacted to them in similar situations in the past, (c) asking patients to describe how the therapist just treated them, and (d) contrasting the therapist's behavior with that of significant others in similar situations.

McCullough's Treating Chronic Depression With Disciplined
Personal Involvement is a breath of fresh air. It is edgy, innovative, gutsy, and engaging. McCullough places his therapeutic approach in context by comparing it with other therapies, making his book both scholarly and absorbing. He presents a high-risk–high-gain approach for chronically depressed patients, an extremely difficult group with which to work. The volume contains extensive and intense patient–therapist dialogue. This dialogue provokes tension, anxiety, and self-reflection in the reader and is extremely useful for conveying a feel for this approach.

Congratulations to McCullough on this remarkable work. He has made an extremely important contribution to both the treatment of chronic depression and the larger literature on the curative power of the therapist–patient relationship.

References
Ingram, R. E., Miranda, J., & Segal, Z. V. (1998). Cognitive Vulnerability to
     Depression. New York: Guilford Press.
Kiesler, D. J. (1996). Contemporary Interpersonal Theory and Research:
     Personality, Psychopathology, and Psychotherapy. New York: Wiley.
Kiesler, D. J. & Schmidt, J. A. (1993). The Impact Message Inventory: Form IIA
     Octant Scale Version. Redwood City,CA: Mind Garden.
Linehan, M. M. (1993). Cognitive–Behavioral Treatment of Borderline Personality
     Disorder. New York: Guilford Press.
McCullough, J. P. (2000). Treatment for Chronic Depression: Cognitive Behavioral
     Analysis System of Psychotherapy. New York: Guilford Press.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema Therapy: A
     Practitioner's Guide. New York: Guilford Press.