Affect Phobia Therapy: Outcome and Process Research Presented by: Maneet Bhatia, MA, Ph.Dc

1. Achievement of Therapeutic Rating Scale (ATOS) 1. Process research in APT 1. Introduce www. ATOStrainer.com

 Numerous meta-analyses have demonstrated the overall efficacy of psychotherapy with large effect size ranging from.75 to.85 (Wampold, 2001)  Psychodynamic tx (inc. STDP) has demonstrated strong empirical support  “Dodo Bird” verdict: All therapies are equally effective (Leichsenring, 2001, Leichsenring & Leibing, 2004)  What are the change variables implicated in effective psychotherapy?

 A process instrument originally created to assess patients' degree of absorption, assimilation or achievement of specific treatment objectives characterized as essential change mechanisms in short- term dynamic psychotherapy

 1. Defence Recognition (Insight): Measures the degree to which patients recognize and understand their own pattern of defensive behaviour  2. Defence Relinquishing (Motivation): Reflects the degree to which the patient is motivated to change or to give up the defensive behaviour

 3. Affect Experiencing (Exposure): Measures the degree of the patient’s emotional arousal of the adaptive affect during the session, whether consciously experienced by the patient or based on visible physiological signs.  4. Affect Expression (New Learning): Measures the degree to which the patient has learned to express adaptive thoughts and feelings in face-to- face interactions outside of therapy or (if relevant) with the therapist in session

 5. Anxiety, Guilt, Shame or Pain (Inhibition): Reflects the degree to which inhibitory affects interfere with affect experiencing.  6. Sense of Self (Self Perception): Measures the degree to which the patient has positive or constructive sense of self.  7. Sense of Others(Alliance and Relations): Measures the degree to which the patient is able to acknowledge and respond to others in a positive way.

THE ATOS SCALE HAS BEEN DEVELOPED AND REVISED FOR OVER 20 YEARS. The ATOS Scale HAS DEMONSTRATED: Good to Excellent Reliability McCullough et al., 2002 Schanche et al., in press Good to Excellent Construct Validity Carley, 2006 Excellent Predictive Validity Valen et al, 2011

Based on data from RCT conducted by Svartberg, Stiles & Seltzer (2005)

 Exposure to Adaptive Affect and Reduction of Inhibition Best predictor of Positive Outcomes  Desensitization Composite Factor to Best Predict Improvement in STDP and CT

Leigh McCullough Workshop Hol LEVEL OF ACTIVATING AFFECT (Grief, Assertion, Tenderness, Care) DESENSITIZATION = LEVEL OF INHIBITORY AFFECT (Anxiety, Guilt, Shame, Pain)

 The Affect Capacity Ratio is a mathematical equation that describes the level of affect a patient is experiencing within a 10 min. segment of psychotherapy and the level of inhibition the patient is experiencing  Affect Capacity Ratio = level of adaptive affect / level of inhibition

 Explore the process of activation and inhibition (approach and avoidance emotions) in relation to outcome in an RCT of STDP and CBT in the treatment of Cluster C personality disorders (Svartberg, Stiles and Seltzer, 2002).  Explore the role of affect in CBT and whether the process is similar to that of STDP  Provide a clearer understanding of underlying change mechanisms in the process of psychotherapy

1. Levels of activation, inhibition and desensitization will be related to outcome. 2. Level of desensitization (the ratio of activation to inhibition) will contribute more to outcome than either activation or inhibition separately. 3. The greater the level of desensitization, the greater the contribution to outcome.

 Patients (N=50) were randomly assigned to CBT or STPD for 40 sessions  All patients met criteria for at least one cluster C personality disorder

 Graduate students completing requirements for a clinical psychology program at Norwegian University of Science and Technology (NTNU) were trained on the ATOS  Raters all achieved IIC of.7 or better  Sessions from early and late in a 40 session-treatment were rated (sessions 6 and 36)

 The STDP therapists were three psychiatrists and five clinical psychologists with a mean of 9.2 years of clinical experience (SD = 3.6).  The CT therapists were six clinical psychologists with a mean of 11.2 years of clinical experience (SD = 4.3).

 SCL-90 symptom index, (Derogatis, 1983)  The 127-item version of the Inventory of Interpersonal Problems (IIP; Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988)  The Millon Clinical Multiaxial Inventory (MCMI; Millon, 1984) as a measure for personality disorders and Cluster C pathology, in particular

 The Working Alliance Scale (WAI: Horvath & Greenberg, 1989) measured the level of the therapeutic bond and working capacity.  The ATOS scale (McCullough et al., 2002) assesed psychotherapy process; i.e., the level of the two affective pathways as they progress over the course of treatment

 Partial Correlations were conducted on activating affects, inhibitory affects and desensitization ratios at two year follow up on three outcome instruments; the SCL-90, the IIP and the MCMI-Cluster C scale.  Hierarchical linear regressions combining both treatment conditions and controlling for pre-treatment, treatment condition, alliance, and their interactions effects were conducted

 Partial correlations comparing STDP and CT conducted separately did not yield significant differences and the two groups were combined for further analyses  Session 6 affect variables were not associated with outcome on three instruments at admission nor at two year follow up, so only session 36 was used in the regression analyses

 Partial correlations showed that the increased level of activating feeling reached by session 36 in STDP was significantly associated with outcome at two year follow- up.  Activation in STDP was significantly associated with two of three measures (IIP, r = -.608, p =.01;MCMI, r =.-.580, p =.01) but not SCL-90  Inhibition was significantly associated with outcome only on the IIP (r =.421; p =.01).

 Activation was significantly associated with improvement on the IIP (r = : p =.01) but was not associated with improvement on the SCL-90 nor MCMI-C.  Inhibition was strongly associated with two measures, (IIP, r =.723, p =.01; MCMI, r =.593, p =.01), but not on the SCL-90

 The desensitization ratio (activation/inhibition) in both STDP and CT showed significant correlations with the IIP ( and respectively) and MCMI (-.630 and -.404) but neither showed significant associations to change on the SCL-90.

 Level of activating affect (at session 36) significantly contributed to the variance in outcome in STDP for the SCL-90 (6.6%) and the MCMI-C (also 6.6%), but only a trend for the IIP (R2 = 4%, p =.09).  The level of inhibitory affect reached by session 36 contributed 7.6% of the variance in outcome at termination on the SCL-90; 15.5% of the variance on the IIP, and 21.0% of the variance on the MCMI-C

 Desensitization ratio reached by session 36 was more strongly correlated with outcome on the SCL, IIP, and MCMI-C than either activation or inhibition separately  At two year follow up the desensitization ratio predicted outcome on the IIP and MCMI, but not the SCL-90.  Desensitization matched inhibition on the IIP (11.% versus 11.1%) but captured more of the variance on the MCMI-C (R2 = 10.9% versus 5.9%.)

 Six patients achieved desensitization at the 50/30 level at session 36 ( 3 each from CT and STDP)  STDP averaged 62 for activation and 22 for inhibition (Ratio= 62/22 or 2.8/1)  CT patients averaged 57 for activation and 16 for inhibition (Ratio= 57/16 or 3.4/1)

 The contribution from the level of inhibitory affect approached the level of alliance on the IIP (inhibition R2 = 15.5%; alliance R2 = 16.7%) and fell short of the alliance on the SCL-90 (inhibition R2 = 7.9%; alliance R2 = 11.9%).  The contribution from the level of inhibitory affect on the MCMI-C (R2= 21%, p=.001) exceeded the non significant contribution of the alliance.  At two year follow up, desensitization contributed 10.9% of the variance on the MCMI-C and alliance contributed nothing

 The contribution due to activation and inhibition at two year follow up on the SCL-90 and IIP (Range; 4.3%- 6.8%) was far less than that contributed by the alliance (Range 20% – 23.6%).  An desensitization ratio significantly contributed to outcome on the SCL-90 and IIP (range 10.9%- 11.0%), yet fell short of contribution of the alliance (Range; 21.3% to 26.5%).  Indicates the power of the alliance as the alliance measured once at session 4 captures over 20% of the variance at two years post treatment!

 The study demonstrates that two affective constructs (activating and inhibitory affects) are significantly related to outcome in psychodynamic as well as cognitive treatment.  Both treatment groups demonstrated the same contribution to desensitization though through different affective pathways (i.e. STDP from Activation and CT from Inhibition).  This study may have identified underlying factors that can lead to an integration of different theoretical orientations to better outcomes.

 STDP had a trend to take the ‘activation road’, and CT had a trend toward taking the ‘inhibition road.’  In STDP, inhibitory feelings were first elicited and increased as defenses were confronted before they were eventually diminished.  CT therapists attempted to quickly reduce inhibition by support and encouragement from the first session.  Moving forward, providing the best combination of techniques in STPD and CT could be used to reach desensitization ratios of 2/1 more frequently

 Psychodynamic therapy focuses on elaborating and exploring feelings and CT focus more on controlling, managing, reducing, and understanding feelings to reduce them (Blagys & Hilsenroth,2000)  Called into question the theoretical framework of CBT of focusing on changing negative beliefs or maladaptive schemas (Weersing and Weisz, 2006)  Confronting defenses and affect are what cause change in both CT and psychodynamic therapy (Ablon & Levy, 2006; Coombs, Coleman & Jones, 2002, Coffman et al, 2007)  Barlow’s unified model also supports the impact of affect (Barlow, 2008)

 Limited number of sessions coded  Important prerequisites to affective desensitization  Generalizability across theoretical orientations

 Future studies in activating and inhibitory affects can examine: 1. Variation in affect categories across diagnostic groups 2. The frequency, intensity and duration of exposure for optimal levels of desensitization 3. The relative contributions of specific activating feelings (e.g., anger, grief, closeness, or self compassion) and inhibitory affects (anxiety, guilt, shame or pain) 4. The therapist interventions most helpful in achieving desensitization

 Findings in both cognitive and dynamic forms of treatment, lend support to the effectiveness and theoretical underpinnings of these affect constructs and merits further study  Affect phobias may underlie many problems and diagnoses, and operate in many treatments, helping us understand how different therapeutic methods often result in similar outcomes.  May lead us to a unified underlying theory of change mechanisms

Bhatia, M., Gil Rodriguez, M., Fowler, D., Godin, J., Drapeau, M. & McCullough, L. (2009). Desensitization to Conflicted Feelings: Using the ATOS to measure early change in a single-case Affect Phobia Therapy treatment. Archives of Psychiatry and Psychotherapy, 1,

 One of the major problems with current clinical trials is their failure to account for the absorption of treatment when evaluating the effects of different treatments on outcome  Greenberg (1996) urges for the study of the link between patient change process and outcome, and for the effects of particular processes to be demonstrated

 Detailed exploration of change mechanisms may provide data relevant to another question of interest in current psychotherapy research: the psychotherapy dose-effect relationship (Howard, Kopta, Kranse & Orlinsky, 1986)  The influence of time-limited psychotherapy and a move towards shorter therapy services makes this question of pivotal importance to service providers (Kopta, 2003)

 Howard et al (1986) has clearly pointed to the significance of early change, and the need to examine session-by-session outcome in the early stages of therapy  Understanding early changes in treatment and identifying the change mechanisms is specially important to clinicians who, in this managed-care era, are under pressure to provide effective relief in the shortest time possible

 To better understand the link between patient change process and outcome  Focus on the first ten sessions of therapy in an attempt to clarify what change occurs in this crucial period in treatment  Assess the degree of activating and inhibitory feelings and their relationship to the patient’s improvement in the first ten sessions of treatment

 Raters consisted of three graduate students at McGill University who received training on the ATOS  The three raters achieved Intra Class Coefficients (ICC) reliabilities of.654,.707, and.708 putting them all in the moderately reliable range for rating the ATOS

 30-year old female entrepreneur who came to treatment due to problems of anxiety, issues in relationships, and lack of self worth  The patient reported having a family that did not “do feelings,” meaning that her family was not emotionally expressive, and she was discouraged from expressing her own feelings

 The Symptoms Checklist 90 Revised (SCL-90-R; Derogatis, 1994)  The Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1965)  Inventory of Interpersonal Problems (IIP; Horowitz, Alden, Wiggins, & Pincus, 2000)  Achievement of Therapeutic Objectives Scale (ATOS; McCullough, Larsen, et al., 2003)

__Changes in depressive and anxious symptoms__ Pre-treatment Mean________Mid-treatment Mean Instrument SCL-90-R GSI DEP ANX Interpersonal Distress_________ Pre-treatment Mean________Mid-treatment Mean Instrument IIP Self-esteem changes__________ Pre-treatment Score______ Mid-treatment_Score Instrument RSE 24 33

ATOS Mean Standard Deviation Insight Motivation Exposure New Learning Inhibition Improvement of the Image of Self Improvement of the Image of Others ______________________________________________________________

 Client made significant improvements by midpoint of therapy  Exposure to warded off ‘activating’ feelings strongly predicts outcome (McCullough & MaGill, 2008)  Desensitization best predicts successful outcome (McCullough et al, 2008)

McCullough, L., Bhatia, M., Ulvenes, P., Berggraf, L. & Osborn, K. (2011). Learning how to rate video-recorded therapy sessions: A Practical Guide for Trainees and Advanced Clinicians. Psychotherapy, 48,

 Athletic performance centers around practice and repetition of proper technique  Large component of skill development occurs through video analysis  Therapists and supervisors can model psychotherapy training after sports training

Select APA video to watch Rate the APA video with the ATOS Request your score Receive data as to how “Expert Raters” coded the video Try Again Receive a Certificate 53

Leigh McCullough: Affect Focused STDP Jeremy Safran: Relational Therapy Scott Miller: Client Directed Outcome Focused TX Jon Carlson: Alderian Therapy Nancy McWilliams: Psychoanalytic Therapy Paul Watchel: Integrative Relational Therapy Gordon Wheeler: Gestalt Therapy Reid Wilson: Obsessive Compulsive Disorder Marvin R. Goldfried: Cognitive-Affective Behavior Therapy 54

 Improves researchers understanding of psychotherapy process  Improves quality of therapeutic work with patients  Enhances therapists understanding of how to use structured techniques in-session  Airplane Pilot Standards: Using video for training

 Requires the purchase of APA tapes  Cannot replace face-to-face supervision or actual therapy experiences  Supervision entails more than just development of skills  e.g. Self-awareness, counter-transference etc  Receiving feedback  Professional identity development

 ATOStrainer is an interactive psychotherapy training website designed for both researchers and clinicians to better understand psychotherapy process and change mechanisms  Therapy, like sports, should utilize video and practice more explicitly, and formally, to increase clinical skill development

 Ablon, J.S. & Levy, R.A. (2006). Beyond brand names of psychotherapy: Identifying empirically supported change processes. Psychotherapy: Theory, Research, Practice, Training, 43(2),  Bhatia, M., McCullough, L., Ulvenes, P., Berggraff, L., & Osborn, K. (2011, June). The future of psychotherapy training: Rating video- recorded sessions as an effective tool for both the beginning therapist and the advanced clinician.  Bhatia, M., Drapeau, M., McCullough, L., Stiles, T. & Svartberg, M. Avoidance and Approach Emotions in Cluster C Personality Disorders. (2009, August). Paper presented at American Psychological Association Annual Convention: Toronto, Ontario, Canada.  Bhatia, M., Gil Rodriguez, M., Fowler, D., Godin, J., Drapeau, M. & McCullough, L. (2009). Desensitization to Conflicted Feelings: Using the ATOS to measure early change in a single-case Affect Phobia Therapy treatment. Archives of Psychiatry and Psychotherapy, 1,  Blagys, M.D. & Hilsenroth, M.J. (2000). Distinctive feature of short-term psychodynamic-interpersonal psychotherapy: A review of the comparative psychotherapy process literature. Clinical Psychology: Science and Practice, 7(2)  Greenberg, L.S. & Foerster, F. S. (1996). Task analysis exemplified: The process of resolving unfinished business. J Consulting and Clinical Psychology, 64: 439–446.  Howard K.I, Kopta, S.M., Kranse, M.S., Orlinsky, D.E. (1986). The dose- effect relationship in psychotherapy. American Psychologist, 4, 159–164.  Leichsenring, F. (2001). Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy on depression: A meta-analytic approach. Clinical Psychology Review, 21,  Leichsenring, F. & Rabung, S. (2004). The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Archives of General Psychiatry, 61,  McCullough, L., Bhatia, M., Ulvenes, P., Berggraf, L. & Osborn, K. (2011). Learning how to rate video-recorded therapy sessions: A Practical Guide for Trainees and Advanced Clinicians. Psychotherapy, 48,  McCullough L, Magill M. (2008). Affect focused short-term dynamic- psychotherapy: Empirically-supported strategies for resolving afect phobias. In: Levy R, Ablon S. Evidence-based psycho- In: Levy R, Ablon S. Evidence-based psycho- dynamic psychotherapy: Clinical currents in psychiatry se ries, Rosenbaum J. ed. NY: Humana Press  McCullough, L., Kuhn, N., Andrews, S., Hatch, D., Valen, J., & Osimo, F. 2002). The reliability of the achievement of therapeutic objectives scale: Five studies, Journal of Brief Psychotherapy, 2, 1–14.  McCullough, L., Larsen, A. E., Schanche, E., Andrews, S., & Kuhn, N. 2003). Achievement of Therapeutic Objectives Scale: Representing well-established common factors in psychotherapy. Retrieved from Retrieved July 17,  McCullough, L., Kuhn, N., Andrews, S., Kaplan, A., Wolf, J., & Hurley, C. L. (2003). Treating affect phobia: A manual for short-term dynamic psychotherapy. New York: The Guildford Press.  Rosenberg M. (1965) Conceiving the Self. Malabar, FL: Krieger  Schanche, E., Hoffart, A., Neilson, G., & McCullough, L. (In press). The effects of varying amounts of training on the reliability of graduate students’ rating of complex clinical phenomena. Scandinavian Journal of Psychotherapy.  Svartberg, M., Stiles, T., & Seltzer, M. (2004). A randomized controlled trial of the effectiveness of short term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. Journal of Consulting and Clinical Psychology, 161, 810 – 817.  Valen, J. (2011). The Achievement of Therapeutic Objective Scale: Inter-rater reliability and sensitivity to change in short-term dynamic psychotherapy and cognitive therapy. Psychological Assessment.  Wampold, B. E. (2001). The great psychotherapy debate. Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum.