Learn to Evaluate Learn to Evaluate Therapy Tapes in Therapy Tapes in a Few Easy Stepsa Few Easy Steps

Some Process Research Some Process Research Implements with a Taste of Implements with a Taste of

Outcome ResearchOutcome Research

Leigh McCullough, Leigh McCullough, PhDPhD

Stuart Andrews, Stuart Andrews, PhDPhD

Nat Kuhn, MDNat Kuhn, MDSCT Annual Conference 2007SCT Annual Conference 2007

Triangle of ConflictTriangle of Conflict

The Defense Pole, The Defense Pole, Anxiety Pole, and Anxiety Pole, and Feeling Pole Feeling Pole represent the three represent the three basic components of basic components of psychodynamic psychodynamic conflictconflict

Defense Anxiety

Feeling

Universal Principle of Universal Principle of Psychodynamic Psychodynamic PsychotherapyPsychotherapy

DefensesDefenses and and AnxietiesAnxieties block the block the expression of adaptive expression of adaptive FeelingsFeelings

Adaptive Adaptive FeelingsFeelings (F pole) include (F pole) include anger, grief, closeness, and positive anger, grief, closeness, and positive feelings about the self, among othersfeelings about the self, among others

Inhibitory feelings (A pole) include Inhibitory feelings (A pole) include anxietyanxiety, guilt, shame, and (emotional) , guilt, shame, and (emotional) painpain

Affect PhobiaAffect Phobia

Psychodynamic conflict arises during Psychodynamic conflict arises during development by a process of development by a process of classical conditioningclassical conditioning

Adaptive affect (F) is paired with Adaptive affect (F) is paired with excessiveexcessive inhibition (A) inhibition (A)

This can be viewed as “Affect This can be viewed as “Affect Phobia”: a phobia about feelingsPhobia”: a phobia about feelings

Systematic Systematic DesensitizationDesensitization

Phobias can be resolved by S.D., a Phobias can be resolved by S.D., a process of graduated exposureprocess of graduated exposure

Effective involves experiencing a Effective involves experiencing a high dose of phobic stimulus (F) with high dose of phobic stimulus (F) with a low degree of anxiety (A)a low degree of anxiety (A)

The Achievement of The Achievement of Therapeutic Objectives Therapeutic Objectives

Scale (ATOS)Scale (ATOS) A psychotherapy coding system that A psychotherapy coding system that measures the degree to which specific measures the degree to which specific therapeutic objectives are achieved or therapeutic objectives are achieved or absorbed by the patientabsorbed by the patient

Evaluates how therapy impacts on a Evaluates how therapy impacts on a patient during each sessionpatient during each session

Sessions divided into 10 minute segmentsSessions divided into 10 minute segments For each segment, the core affective For each segment, the core affective

conflict is identifiedconflict is identified Achievement of each objective is rated 1-Achievement of each objective is rated 1-

100100

ATOS (continued)ATOS (continued)

ATOS designed to assess common factors ATOS designed to assess common factors in therapyin therapy

Currently used to evaluate Short-term Currently used to evaluate Short-term Dynamic Psychotherapy and Cognitive Dynamic Psychotherapy and Cognitive Therapy from videotaped sessions in Therapy from videotaped sessions in study in Norway (Svartberg, Stiles, & study in Norway (Svartberg, Stiles, & Seltzer, 2004)Seltzer, 2004)

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

The ATOS as a Learning The ATOS as a Learning ToolTool

ATOS is also a helpful learning tool for ATOS is also a helpful learning tool for learning psychotherapylearning psychotherapy

Coding with ATOS while watching Coding with ATOS while watching videotapes of psychotherapy sessions videotapes of psychotherapy sessions involves intensive analysis of micro involves intensive analysis of micro processes in treatmentprocesses in treatment

Jakobsladder – a web-based reliability and Jakobsladder – a web-based reliability and training tool for psychotherapy process training tool for psychotherapy process evaluationevaluation

7 Treatment Objectives7 Treatment Objectives(in Common Factors and STDP (in Common Factors and STDP

terminology)terminology)1) Awareness or Insight of maladaptive behaviors (Defense

Recognition)2) Motivation to Change (Defense Relinquishing)3) Affect Arousal/Exposure (Affect Experiencing)4) New Learning (Affect Expression)5) Degree of Inhibition (anxiety, guilt, shame, or emotional

pain – the Anxiety Pole on Malan´s Triangle)6) Improvement in the Sense of Self (Self Restructuring)7) Improvement in Relations with Others (Other Restructuring)

Awareness or Insight Awareness or Insight (Defense Recognition)(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

MotivationMotivation(Defense Relinquishing)(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 Exposure to Adaptive FeelingsFeelings

(Affect Experiencing)(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 LearningNew Learning((Affect Expression)Affect Expression)

Goal: to help patients integrate and Goal: to help patients integrate and express feelings adaptively in all of express feelings adaptively in all of their relationships (the ultimate goal their relationships (the ultimate goal of treatment) of treatment)

Key interventions: skills training in Key interventions: skills training in communication, social skills and communication, social skills and assertiveness, role playing for skills assertiveness, role playing for skills practice (in vivo desensitization)practice (in vivo desensitization)

Degree of InhibitionDegree of Inhibition ( (Anxiety, Guilt, Shame, or Anxiety, Guilt, Shame, or

Emotional Pain)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 Adaptiveness of Self Image Image

(Self Restructuring)(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 Adaptiveness of Image of OthersOthers

((Other Restructuring)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 FlashResearch Flash

Desensitization = high activating Desensitization = high activating affect and low inhibitory affectaffect and low inhibitory affect

D = Exposure – InhibitionD = Exposure – Inhibition D beats alliance as predictor of D beats alliance as predictor of

outcome!outcome! For STDP, exposure is secondFor STDP, exposure is second For CT, reduction of inhibition is For CT, reduction of inhibition is

secondsecond

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10 min. segments / 1,2,3,.. Sessions / I,II,III,....

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fisiological activation

inhibition

DENSENSITIZATION

In 9 Session Treatment

3 Hr Initial Evaluation Session I II III IV VI VII VIII IXV

Adaptations of the ATOS Adaptations of the ATOS as a Tool in Group as a Tool in Group

TherapyTherapy After each group session, ask patients After each group session, ask patients to: to: 1) identify their core feeling from the 1) identify their core feeling from the sessionsession2) Rate themselves on Self Compassion2) Rate themselves on Self Compassion3) Write down main themes from the 3) Write down main themes from the sessionsession

Group leaders can give their own Group leaders can give their own ratings as a measure of exposure to ratings as a measure of exposure to conflicted affects. conflicted affects.