Title: Affect Phobia Therapy: Outcome and Process Research
1- Affect Phobia Therapy Outcome and Process
Research - Â
- Presented by
- Maneet Bhatia, MA, Ph.Dc
2Outline
- Achievement of Therapeutic Rating Scale (ATOS)
- Process research in APT
- Introduce www. ATOStrainer.com
3Psychotherapy
- 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?
4Achievement of Therapeutic Objectives Scale
5What 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
6ATOS
- 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
7ATOS
- 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
8ATOS
- 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
10Approach and Avoidance Emotions in Cluster C
Personality DisordersBhatia, Drapeau,
McCullough, Stiles Svartberg (2009)
- Based on data from RCT conducted by Svartberg,
Stiles Seltzer (2005)
11Exposure 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
12Â LEVEL OF
ACTIVATING AFFECT
(Grief, Assertion, Tenderness, Care) DESENSITIZATI
ON ---------------------
-----------------------
LEVEL OF INHIBITORY AFFECT
(Anxiety, Guilt, Shame, Pain) Â
13The 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
14Goals
- 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
15Hypotheses
- 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.
16Demographics
- Patients (N50) were randomly assigned to CBT or
STPD for 40 sessions - All patients met criteria for at least one
cluster C personality disorder
17Raters
- 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)
18Therapists
- 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).
19Measures
- 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
20Process 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
21Statistical 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
22Statistical 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
23Results 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).
24Hypothesis 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
25Desensitization 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.
26Impact 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
27Hypothesis 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.)
28Affect 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)
29Alliance 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
30Alliance 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!
31Summary
- 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.
32STDP 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
33Comparison 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)
34Limitations
- Limited number of sessions coded
-
- Important prerequisites to affective
desensitization - Generalizability across theoretical orientations
35Future 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
36Conclusions
- 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
37The 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.
38Introduction
- 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
39Introduction 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)
40Introduction
- 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
41Goals 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
42Raters
- 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
43Method 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
44Measures
- 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)
45Results 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
46Results 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 - __________________________________________________
____________
47Results Exposure Inhibition
48Results Peak Exposure Inhibition
49Results Desensitization
50Discussion
- 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)
51www.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.
52Practice 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
53www.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
54www.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
55Benefits 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
56Limitations 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
57Take 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
58References
- Ablon, J.S. Levy, R.A. (2006). Beyond brand
names of psychotherapy Identifying empirically
supported change processes. Psychotherapy
Theory, Research, Practice, Training, 43(2),
216-231. - 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, 31-38. - Blagys, M.D. Hilsenroth, M.J. (2000).
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