Learn to Evaluate Therapy Tapes in a Few Easy Steps

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

2. Leigh McCullough, PhDStuart Andrews, PhDNat Kuhn, MD SCT Annual Conference 2007

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

4. Universal Principle of Psychodynamic Psychotherapy • 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 • Inhibitory feelings (A pole) include anxiety, guilt, shame, and (emotional) pain

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

6. Systematic Desensitization • 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)

7. 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 • Evaluates how therapy impacts on a patient during each session • Sessions divided into 10 minute segments • For each segment, the core affective conflict is identified • Achievement of each objective is rated 1-100

8. ATOS (continued) • 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) • ATOS has demonstrated good reliability in 5 studies (McCullough, et al., 2001) and good to excellent reliability in 2 studies

9. The ATOS as a Learning Tool • 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 • Jakobsladder – a web-based reliability and training tool for psychotherapy process evaluation

10. 7 Treatment Objectives(in Common Factors and STDP terminology) • Awareness or Insight of maladaptive behaviors (Defense Recognition) • Motivation to Change (Defense Relinquishing) • Affect Arousal/Exposure (Affect Experiencing) • New Learning (Affect Expression) • Degree of Inhibition (anxiety, guilt, shame, or emotional pain – the Anxiety Pole on Malan´s Triangle) • Improvement in the Sense of Self (Self Restructuring) • Improvement in Relations with Others (Other Restructuring)

11. 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

12. 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 _______?¨)

13. 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

14. New Learning(Affect Expression) • 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)

15. 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.

16. 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)

17. 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¨

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

19. DENSENSITIZATION In 9 Session Treatment 3 Hr Initial Evaluation Session I II III IV V VI VII VIII IX

20. Adaptations of the ATOS as a Tool in Group Therapy • 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.