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

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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

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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

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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.

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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
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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)

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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

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  LEVEL OF
ACTIVATING AFFECT
(Grief, Assertion, Tenderness, Care) DESENSITIZATI
ON ---------------------
-----------------------
LEVEL OF INHIBITORY AFFECT
(Anxiety, Guilt, Shame, Pain)  
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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

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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

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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.

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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

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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)
  

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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).

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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

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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

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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

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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).

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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

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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.

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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

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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.)

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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)

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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

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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!
  

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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.

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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

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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)

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Limitations

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

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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

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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

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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.

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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

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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)

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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

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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
• __________________________________________________
  ____________

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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)

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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

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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

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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., Drapeau, M., McCullough, L., Stiles,
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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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