Les dépressions chroniques sont fréquentes et souvent traitées par des approches traditionnelles. Cet article vise à présenter la nature spécifique de la psychopathologie et un traitement spécifiquement adapté à ces patients avec dépression chronique. Nous décrirons d’abord les spécificités psychopathologiques de cette population, en nous référant aux travaux de J. Piaget et de D. Kiesler. À partir de ces théories, nous mettrons en avant le modèle Cognitive Behavioral Analysis System of Psychotherapy (CBASP), selon McCullough. Cet auteur propose deux volets d’interventions spécifiquement adaptées aux patients avec dépression chronique : l’analyse situationnelle et les techniques interpersonnelles basées sur la notion de transfert et de contre-transfert. Nous soulignerons la pertinence de cette approche par le résumé de plusieurs études empiriques ayant établi l’efficacité de ce modèle, sous certaines conditions cliniques. Nous terminerons par une réflexion de l’application de ce modèle au-delà du tableau clinique de la dépression chronique en ajoutant ainsi des arguments supplémentaires en faveur de l’apport du modèle CBASP au champ actuel de la psychothérapie des troubles mentaux.

Chronic depression is a frequent disorder and is usually treated using traditional approaches. These approaches rarely take into account the psychopathological specificities of the chronic evolution of the disorder.

The present article aims at presenting the specific psychopathological nature of chronic depression and puts forward a treatment model that is particularly adapted to these specificities.

The treatment model, Cognitive Behavioral Analysis System of Psychotherapy (CBASP; according to McCullough) is based on two theoretical models: the developmental theory by J. Piaget and the interpersonal model by D. Kiesler. According to McCullough, the cognitive affective functioning of chronically depressed patients is comparable with the one of a child who has not reached the Piagetian stage of logical operations. Their thinking is global, pre-logical and presents with monologues, instead of internal dialogues. These patients are incapable of effective controlling and regulating of emotions and of constructive accommodation of established schemas, when confronted with novel experiences. Finally, these patients are unaware of their interpersonal effects on the environment they unwillingly have. The latter are conceptualized using Kiesler’s conceptualization of psychopathology. According to this model, the patient sends implicit relational “messages” provoking interpersonal “pulls” in the interaction partner (e.g., the therapist). These pulls are assessed and may be graphically represented using a Circumplex Model, also called the Kiesler-circle, and is the basis of the case conceptualization in the psychotherapy with chronically depressed patients. CBASP has developed based on the clinical implications of these models and combines them in an original fashion.

Two lines of intervention result from the models: (1) situational analysis, which analyzes the links between behavior in a particular situation and the person’s goal or desire related to the particular situation, and (2) interpersonal techniques based on the notions of transference and counter-transference. On one hand, situational analysis follows several steps linking the patient’s behavior with his/her desired outcome, which is compared to the real outcome in the situation. The patient’s interpretations are amended in a second step, using the desired outcome as an anchor. On the other hand, interpersonal techniques imply the therapist’s stance of disciplined personal involvement, meaning a controlled way of therapist self-disclosure facing the patient, with the aim of experiencing by the patient, that his/her behavior does not remain without specific, immediate and authentic consequences in the environment. This experience by the patient should allow him/her to (re-)establish the perceived functionality of the patient’s behavior in interpersonal encounters.

We underline the relevance of the approach by citing several empirical studies which have established the efficacy of the model, in specific clinical conditions that are the combined treatment with anti-depressant medication, a sufficient number of sessions and in the case of early trauma as etiological factor of the chronic depression. We discuss the application of CBASP to other clinical diagnoses, such as borderline and avoidant personality disorder as well as disorders related to substance abuse and thus argue in favor of CBASP as a central model in the treatment of various mental illnesses.