. 2022 Jul 12;12(7):e057672. doi: 10.1136/bmjopen-2021-057672

Table 2.

Content and implementation of modules

CBASP MODULE Corresponding RDoC domain: Negative valence system - Social threat response Indicative questionnaire: Rejection Sensitivity Questionnaire (RSQ) Objective: ‘Retraining’ the negative valence system (social threat response) and reducing avoidance behaviour
The CBASP module includes interpersonal discrimination training between abusing and well meaning others based on continued safety signals given by the therapist.²⁸ As a first step, a so-called ‘Significant Other History’ (SOH) is conducted, a short procedure listing significant others who left an interpersonal-emotional ‘stamp’ in the patient’s learning history. From the SOH, causal conclusions are derived (eg, ‘Growing up with my mother led to the pervasive assumption that I have nothing to expect from others’). Based on the patient’s assumptions about relationships the patient experienced in his/her history with abusive significant others, a proactive ‘transference hypothesis’ is formulated stating the patient’s most relevant interpersonal expectation/fear regarding the therapist-patient encounter The transference hypothesis is then systematically contrasted with the therapist’s actual behaviour in ‘hot spot situations’, applying the structured ‘Interpersonal Discrimination Exercise’. By means of this exposure procedure, the patient learns to differentiate the abusive significant other (generalised to his/her social environment) from current non-abusive or well-intended persons by discrimination learning. Thus, the patient is enabled to overlearn dysfunctional expectations and reprogram the conditioned social threat systems. In addition, by enriching safety signals in therapists’ behaviour and re-establishing the perception of operant interpersonal contingencies, this intervention is designed to provide a secure learning environment to decrease interpersonal threat sensitivity. In addition, teaching the patient the mechanisms of complementary interpersonal processes illustrated by Kiesler’s circumplex model¹⁰² enables the patient to recognise the consequences of his/her own behaviour on other persons and to develop empathy (‘reading others’) and social problem-solving skills (element of CBASP). Genuine empathy and theory of mind skills are furthermore facilitated by the therapist’s ‘Disciplined Personal Involvement’ (DPI) and more specifically ‘Contingent Personal Reactivity’ (CPR), that is, expressing personal emotional reactions to the patients dysfunctional behaviour patterns in a disciplined way (including considering a teachable moment and relating it to the patient’s core pathology) and offering alternative behaviour. The key objective of this module is social fear extinction by overlearning conditioned associations and avoidance behaviour.

CBASP MODULE

Corresponding RDoC domain: Negative valence system - Social threat response
Indicative questionnaire: Rejection Sensitivity Questionnaire (RSQ)
Objective: ‘Retraining’ the negative valence system (social threat response) and reducing avoidance behaviour

The CBASP module includes interpersonal discrimination training between abusing and well meaning others based on continued safety signals given by the therapist.²⁸ As a first step, a so-called ‘Significant Other History’ (SOH) is conducted, a short procedure listing significant others who left an interpersonal-emotional ‘stamp’ in the patient’s learning history. From the SOH, causal conclusions are derived (eg, ‘Growing up with my mother led to the pervasive assumption that I have nothing to expect from others’). Based on the patient’s assumptions about relationships the patient experienced in his/her history with abusive significant others, a proactive ‘transference hypothesis’ is formulated stating the patient’s most relevant interpersonal expectation/fear regarding the therapist-patient encounter The transference hypothesis is then systematically contrasted with the therapist’s actual behaviour in ‘hot spot situations’, applying the structured ‘Interpersonal Discrimination Exercise’. By means of this exposure procedure, the patient learns to differentiate the abusive significant other (generalised to his/her social environment) from current non-abusive or well-intended persons by discrimination learning. Thus, the patient is enabled to overlearn dysfunctional expectations and reprogram the conditioned social threat systems. In addition, by enriching safety signals in therapists’ behaviour and re-establishing the perception of operant interpersonal contingencies, this intervention is designed to provide a secure learning environment to decrease interpersonal threat sensitivity. In addition, teaching the patient the mechanisms of complementary interpersonal processes illustrated by Kiesler’s circumplex model¹⁰² enables the patient to recognise the consequences of his/her own behaviour on other persons and to develop empathy (‘reading others’) and social problem-solving skills (element of CBASP). Genuine empathy and theory of mind skills are furthermore facilitated by the therapist’s ‘Disciplined Personal Involvement’ (DPI) and more specifically ‘Contingent Personal Reactivity’ (CPR), that is, expressing personal emotional reactions to the patients dysfunctional behaviour patterns in a disciplined way (including considering a teachable moment and relating it to the patient’s core pathology) and offering alternative behaviour. The key objective of this module is social fear extinction by overlearning conditioned associations and avoidance behaviour.

MENTALISING MODULE Corresponding RDoC domain: System for social srocesses Indicative questionnaire: Interpersonal Reactivity Index (IRI) Objective: Enhancing perception and understanding of self and others (understanding mental states) and social communication
The mentalising module contains modelling and teaching mentalising by learning to ‘read’ others' behaviour and thereby reconnecting the patient to his/her social environment and creating social competence. To promote mentalised affectivity (ie, mentalising own emotional states as described by MBT), the therapist introduces repetitive sequences to stimulate basic mentalising functions in the patient. Based on empathy, the therapist uses a ‘not knowing’ stance of exploration of the patients’ experiences and identifies context-related emotional reactions, raising ‘what-questions’ rather than ‘why-questions’. Two typical interventions to engage mentalising are the ‘Stop and Stand’ and the ‘Stop, Re-wind, Explore’ sequences⁶⁸ In the first case, the therapist stops a patient who is stuck in drawing non-mentalising assumptions (eg, ‘everybody hates me’) by surprise or humour to subsequently help the patient to mentalise about his/her experiences. The second sequence generates a joined attention on the patients past experiences by shifting the focus back and forth within an episodic experience to make it accessible for the mentalising process. Genuine empathy and theory of mind skills are furthermore facilitated by the therapist’s ‘DPI’ (and more specifically ‘CPR’ as an element of CBASP as well. The key objective of this module is to improve mentalising capabilities in social interactions.

MENTALISING MODULE

Corresponding RDoC domain: System for social srocesses
Indicative questionnaire: Interpersonal Reactivity Index (IRI)
Objective: Enhancing perception and understanding of self and others (understanding mental states) and social communication

The mentalising module contains modelling and teaching mentalising by learning to ‘read’ others' behaviour and thereby reconnecting the patient to his/her social environment and creating social competence. To promote mentalised affectivity (ie, mentalising own emotional states as described by MBT), the therapist introduces repetitive sequences to stimulate basic mentalising functions in the patient. Based on empathy, the therapist uses a ‘not knowing’ stance of exploration of the patients’ experiences and identifies context-related emotional reactions, raising ‘what-questions’ rather than ‘why-questions’. Two typical interventions to engage mentalising are the ‘Stop and Stand’ and the ‘Stop, Re-wind, Explore’ sequences⁶⁸ In the first case, the therapist stops a patient who is stuck in drawing non-mentalising assumptions (eg, ‘everybody hates me’) by surprise or humour to subsequently help the patient to mentalise about his/her experiences. The second sequence generates a joined attention on the patients past experiences by shifting the focus back and forth within an episodic experience to make it accessible for the mentalising process. Genuine empathy and theory of mind skills are furthermore facilitated by the therapist’s ‘DPI’ (and more specifically ‘CPR’ as an element of CBASP as well. The key objective of this module is to improve mentalising capabilities in social interactions.

MINDFULNESS MODULE Corresponding RDoC domain: Arousal system - hyperarousal Indicative questionnaire: Difficulties in Emotion Regulation (DERS-16) Objective: Reducing the arousal system (hyperarousal) referring to emotion awareness and regulation
This module integrates mindfulness-based exercises, which focus on (1) observing non-judgmentally internal and external stimuli, (2) shifting attention away from trauma-related inner ‘movies’ and monitoring skills to (3) overcome hyperarousal and experiential avoidance or being run over by one’s emotions. Mindfulness-based interventions aim to change a person’s perspective on his or her emotions and cognitions. This process is facilitated through mindfulness meditation (eg, body scan, formal sitting meditation) in which close attention is paid to the present moment while thoughts, feelings and body sensations are noted with an attitude of curiosity, non-judgement, and acceptance of psychological experiences. Mindfulness has been suggested to be effective via four mechanisms: attention regulation, body awareness, changes in perspective on the self, and emotion regulation.^{103 104} Mindfulness training enhances positive affect,¹⁰⁵ decreases negative affect, and reduces maladaptive automatic emotional responses¹⁰⁶ being associated with changes in areas of the brain responsible for affect regulation and stress impulse reaction.^{103 107} The key objective of this module is to improve emotion awareness and regulation in order to mitigate hyperarousal.

MINDFULNESS MODULE

Corresponding RDoC domain: Arousal system - hyperarousal
Indicative questionnaire: Difficulties in Emotion Regulation (DERS-16)
Objective: Reducing the arousal system (hyperarousal) referring to emotion awareness and regulation

This module integrates mindfulness-based exercises, which focus on (1) observing non-judgmentally internal and external stimuli, (2) shifting attention away from trauma-related inner ‘movies’ and monitoring skills to (3) overcome hyperarousal and experiential avoidance or being run over by one’s emotions. Mindfulness-based interventions aim to change a person’s perspective on his or her emotions and cognitions. This process is facilitated through mindfulness meditation (eg, body scan, formal sitting meditation) in which close attention is paid to the present moment while thoughts, feelings and body sensations are noted with an attitude of curiosity, non-judgement, and acceptance of psychological experiences. Mindfulness has been suggested to be effective via four mechanisms: attention regulation, body awareness, changes in perspective on the self, and emotion regulation.^{103 104} Mindfulness training enhances positive affect,¹⁰⁵ decreases negative affect, and reduces maladaptive automatic emotional responses¹⁰⁶ being associated with changes in areas of the brain responsible for affect regulation and stress impulse reaction.^{103 107} The key objective of this module is to improve emotion awareness and regulation in order to mitigate hyperarousal.

CBASP, Cognitive Behavioural Analysis System of Psychotherapy; DERS-16, Difficulties in Emotion Regulation Scale-16; MBT, Mentalisation-based Psychotherapy; RDoC, Research Domain Criteria.