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Title: Affect Phobia Therapy: Outcome and Process Research


1
  • Affect Phobia Therapy Outcome and Process
    Research
  •  
  • Presented by
  • Maneet Bhatia, MA, Ph.Dc

2
Outline
  • Achievement of Therapeutic Rating Scale (ATOS)
  • Process research in APT
  • Introduce www. ATOStrainer.com

3
Psychotherapy
  • 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?

4
Achievement of Therapeutic Objectives Scale
5
What is the ATOS scale?
  • 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

6
ATOS
  • 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

7
ATOS
  • 3.  Affect Experiencing (Exposure) Measures the
    degree of the patients 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

8
ATOS
  • 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.

9
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
10
Approach and Avoidance Emotions in Cluster C
Personality DisordersBhatia, Drapeau,
McCullough, Stiles Svartberg (2009)
  • Based on data from RCT conducted by Svartberg,
    Stiles Seltzer (2005)

11
Exposure Desensitization
  • Exposure to Adaptive Affect and Reduction of
    Inhibition
  • Best predictor of Positive Outcomes
  • Desensitization
  • Composite Factor to Best Predict Improvement in
    STDP and CT

12
  LEVEL OF
ACTIVATING AFFECT
(Grief, Assertion, Tenderness, Care) DESENSITIZATI
ON ---------------------
-----------------------
LEVEL OF INHIBITORY AFFECT
(Anxiety, Guilt, Shame, Pain)  
13
The Affect Capacity Ratio
  • 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

14
Goals
  • 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

15
Hypotheses
  • Levels of activation, inhibition and
    desensitization will be related to outcome.
  • Level of desensitization (the ratio of activation
    to inhibition) will contribute more to outcome
    than either activation or inhibition separately.
  • The greater the level of desensitization, the
    greater the contribution to outcome.

16
Demographics
  • Patients (N50) were randomly assigned to CBT or
    STPD for 40 sessions
  • All patients met criteria for at least one
    cluster C personality disorder

17
Raters
  • 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)

18
Therapists
  • 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).

19
Measures
  • 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

20
Process Measures
  • 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

21
Statistical Analyses
  • 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

22
Statistical Analyses
  • 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

23
Results Hypothesis 1
  • 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
    .01MCMI, r .-.580, p .01) but not SCL-90
  • Inhibition was significantly associated with
    outcome only on the IIP (r .421 p .01).

24
Hypothesis 1 CT
  • Activation was significantly associated with
    improvement on the IIP (r -.331 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

25
Desensitization Ratio
  • The desensitization ratio (activation/inhibition)
    in both STDP and CT showed significant
    correlations with the IIP ( -.511 and -.548
    respectively) and MCMI (-.630 and -.404) but
    neither showed significant associations to change
    on the SCL-90.

26
Impact on Outcome
  • 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

27
Hypothesis 2 Desensitization better indicator of
successful outcome?
  • 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.)

28
Affect Capacity Ratio
  • 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)

29
Alliance and Affect
  • 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

30
Alliance and Affect
  • 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!

31
Summary
  • 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.

32
STDP CT Clinical Implications
  • 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

33
Comparison to other research
  • 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)
  • Barlows unified model also supports the impact
    of affect (Barlow, 2008)

34
Limitations
  • Limited number of sessions coded
  • Important prerequisites to affective
    desensitization
  • Generalizability across theoretical orientations

35
Future Directions
  • Future studies in activating and inhibitory
    affects can examine
  • Variation in affect categories across diagnostic
    groups
  • The frequency, intensity and duration of exposure
    for optimal levels of desensitization
  • The relative contributions of specific activating
    feelings (e.g., anger, grief, closeness, or self
    compassion) and inhibitory affects (anxiety,
    guilt, shame or pain)
  • The therapist interventions most helpful in
    achieving desensitization

36
Conclusions
  • 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

37
The Caterer
  • 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, 31-38.

38
Introduction
  • 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

39
Introduction Dose-effect relationship
  • 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)

40
Introduction
  • 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

41
Goals of present study
  • 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 patients
    improvement in the first ten sessions of treatment

42
Raters
  • 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

43
Method Client
  • 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

44
Measures
  • 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)

45
Results Outcome Measures

  • __Changes in depressive and anxious symptoms__

  • Pre-treatment Mean________Mid-treatment Mean
  • Instrument
  • SCL-90-R
  • GSI
    2.64
    0.93
  • DEP
    2.46 1.00
  • ANX
    2.60
    0.90

  • Interpersonal
    Distress_________

  • Pre-treatment Mean________Mid-treatment Mean
  • Instrument
  • IIP 2.04
    0.91

  • Self-esteem changes__________

  • Pre-treatment Score______ Mid-treatment_Score
  • Instrument
  • RSE
    24
    33

46
Results ATOS ratings
  • ATOS
    Mean Standard Deviation
  • Insight
    70.27 12.64
  • Motivation
    60.86 12.81
  • Exposure
    45.24 23.89
  • New Learning
    48.70 25.40
  • Inhibition
    57.13 21.10
  • Improvement of the Image of Self
    63.15
  • Improvement of the Image of Others
    73.75
  • __________________________________________________
    ____________

47
Results Exposure Inhibition
48
Results Peak Exposure Inhibition
49
Results Desensitization
50
Discussion
  • 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)

51
www.ATOStrainer.com
  • 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, 127-137.

52
Practice makes perfector good enough
  • 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

53
www.atostrainer.com
  • 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

54
www.atostrainer.com
  • 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

55
Benefits of ATOStrainer
  • 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

56
Limitations of ATOS trainer
  • 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

57
Take home message
  • 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

58
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  • 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, 31-38.
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