Learn to Evaluate Therapy Tapes in a Few Easy Steps Some Process Research Implements with a Taste of Outcome Research

Leigh McCullough, PhD Stuart Andrews, PhD Nat Kuhn, MD SCT Annual Conference 2007

Triangle of Conflict The Defense Pole, Anxiety Pole, and Feeling Pole represent the three basic components of psychodynamic conflict The Defense Pole, Anxiety Pole, and Feeling Pole represent the three basic components of psychodynamic conflict Defense Anxiety Feeling

Universal Principle of Psychodynamic Psychotherapy Defenses and Anxieties block the expression of adaptive Feelings Defenses and Anxieties block the expression of adaptive Feelings Adaptive Feelings (F pole) include anger, grief, closeness, and positive feelings about the self, among others Adaptive Feelings (F pole) include anger, grief, closeness, and positive feelings about the self, among others Inhibitory feelings (A pole) include anxiety, guilt, shame, and (emotional) pain Inhibitory feelings (A pole) include anxiety, guilt, shame, and (emotional) pain

Affect Phobia Psychodynamic conflict arises during development by a process of classical conditioning Psychodynamic conflict arises during development by a process of classical conditioning Adaptive affect (F) is paired with excessive inhibition (A) Adaptive affect (F) is paired with excessive inhibition (A) This can be viewed as “Affect Phobia”: a phobia about feelings This can be viewed as “Affect Phobia”: a phobia about feelings

Systematic Desensitization Phobias can be resolved by S.D., a process of graduated exposure Phobias can be resolved by S.D., a process of graduated exposure Effective involves experiencing a high dose of phobic stimulus (F) with a low degree of anxiety (A) Effective involves experiencing a high dose of phobic stimulus (F) with a low degree of anxiety (A)

The Achievement of Therapeutic Objectives Scale (ATOS) A psychotherapy coding system that measures the degree to which specific therapeutic objectives are achieved or absorbed by the patient A psychotherapy coding system that measures the degree to which specific therapeutic objectives are achieved or absorbed by the patient Evaluates how therapy impacts on a patient during each session Evaluates how therapy impacts on a patient during each session Sessions divided into 10 minute segments Sessions divided into 10 minute segments For each segment, the core affective conflict is identified For each segment, the core affective conflict is identified Achievement of each objective is rated Achievement of each objective is rated 1-100

ATOS (continued) ATOS designed to assess common factors in therapy ATOS designed to assess common factors in therapy Currently used to evaluate Short-term Dynamic Psychotherapy and Cognitive Therapy from videotaped sessions in study in Norway (Svartberg, Stiles, & Seltzer, 2004) Currently used to evaluate Short-term Dynamic Psychotherapy and Cognitive Therapy from videotaped sessions in study in Norway (Svartberg, Stiles, & Seltzer, 2004) ATOS has demonstrated good reliability in 5 studies (McCullough, et al., 2001) and good to excellent reliability in 2 studies ATOS has demonstrated good reliability in 5 studies (McCullough, et al., 2001) and good to excellent reliability in 2 studies

The ATOS as a Learning Tool ATOS is also a helpful learning tool for learning psychotherapy ATOS is also a helpful learning tool for learning psychotherapy Coding with ATOS while watching videotapes of psychotherapy sessions involves intensive analysis of micro processes in treatment Coding with ATOS while watching videotapes of psychotherapy sessions involves intensive analysis of micro processes in treatment Jakobsladder – a web-based reliability and training tool for psychotherapy process evaluation Jakobsladder – a web-based reliability and training tool for psychotherapy process evaluation

7 Treatment Objectives (in Common Factors and STDP terminology) 1) 1) Awareness or Insight of maladaptive behaviors (Defense Recognition) 2) 2) Motivation to Change (Defense Relinquishing) 3) 3) Affect Arousal/Exposure (Affect Experiencing) 4) 4) New Learning (Affect Expression) 5) 5) Degree of Inhibition (anxiety, guilt, shame, or emotional pain – the Anxiety Pole on Malan´s Triangle) 6) 6) Improvement in the Sense of Self (Self Restructuring) 7) 7) Improvement in Relations with Others (Other Restructuring)

Awareness or Insight (Defense Recognition) Goal: help patients see their defenses and understand the role defenses play in avoiding the conflicts of Affect Phobias Key Interventions: 1) identify defenses and gently point them out to patients; 2) begin to speculate about what is being defended against (adaptive feelings) and why (anxieties); 3) provide support to regulate patient´s anxieties as defenses are pointed out

Motivation (Defense Relinquishing) Goal: help motivate patients to give up maladaptive defensive responses and replace them with more adaptive responses Key interventions: 1) Help patients understand and feel the costs of the defenses; 2) Help patients distinguish the origin of defenses from their maintenance; 3) Help patients manage the anxiety of change: ¨What´s the hardest part about _______?¨)

Exposure to Adaptive Feelings (Affect Experiencing) Goal: help patients experience adaptive but warded off affects (the Feeling Pole on the Triangle of Conflict) until anxiety subsides Affect Experiencing is the heart of STDP: systematic desensitization of Affect Phobias Key intervention: guided imagery - allowing patients to experience the affect cognitively (in thought) and physiologically (in the body) and imagine actions and behaviors that flow from that affect

New Learning (Affect Expression) Goal: to help patients integrate and express feelings adaptively in all of their relationships (the ultimate goal of treatment) Goal: to help patients integrate and express feelings adaptively in all of their relationships (the ultimate goal of treatment) Key interventions: skills training in communication, social skills and assertiveness, role playing for skills practice (in vivo desensitization) Key interventions: skills training in communication, social skills and assertiveness, role playing for skills practice (in vivo desensitization)

Degree of Inhibition ( Anxiety, Guilt, Shame, or Emotional Pain) Goal: Regulate patient´s anxiety or inhibition (Anxiety Pole on Malan´s Triangle) Key Intervention: Anxiety Regulation. In STDP, anxiety or inhibition must be regulated to be kept within bearable limits to the patient.

Adaptiveness of Self Image (Self Restructuring) Goals: help patients to 1) view the self with compassion (both strengths and vulnerabilities); 2) respond to needs for autonomy as well as independence; 3) become their own good parents Examples of Key Interventions: 1) Changing Perspectives; 2) Parenting of the Self (Adult- Child Work)

Adaptiveness of Image of Others (Other Restructuring) Goals: help patients to 1) perceive others´ strengths and vulnerabilities accurately and compassionately 2) build receptivity to others´ feelings while maintaining an adaptive balance between autonomy and interdependence Examples of Key Interventions: 1) Changing Perspectives, 2) Recovery of ¨Lost Loves¨

Research Flash Desensitization = high activating affect and low inhibitory affect Desensitization = high activating affect and low inhibitory affect D = Exposure – Inhibition D = Exposure – Inhibition D beats alliance as predictor of outcome! D beats alliance as predictor of outcome! For STDP, exposure is second For STDP, exposure is second For CT, reduction of inhibition is second For CT, reduction of inhibition is second

DENSENSITIZATION In 9 Session Treatment 3 Hr Initial Evaluation Session IIIIIIIVVIVIIVIIIIXV

Adaptations of the ATOS as a Tool in Group Therapy After each group session, ask patients to: After each group session, ask patients to: 1) identify their core feeling from the session 2) Rate themselves on Self Compassion 3) Write down main themes from the session Group leaders can give their own ratings as a measure of exposure to conflicted affects. Group leaders can give their own ratings as a measure of exposure to conflicted affects.