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Learn to Evaluate Therapy Tapes in a Few Easy Steps. Some Process Research Implements with a Taste of Outcome Research. Leigh McCullough, PhD Stuart Andrews, PhD Nat Kuhn, MD. SCT Annual Conference 2007. Triangle of Conflict. Anxiety. Defense.

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Learn to evaluate therapy tapes in a few easy steps l.jpg

Learn to Evaluate Therapy Tapes in a Few Easy Steps

Some Process Research Implements with a Taste of Outcome Research

Leigh mccullough phd stuart andrews phd nat kuhn md l.jpg

Leigh McCullough, PhDStuart Andrews, PhDNat Kuhn, MD

SCT Annual Conference 2007

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Triangle of Conflict



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


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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

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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

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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)

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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

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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

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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

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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)

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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

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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 _______?¨)

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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

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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)

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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.

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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)

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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¨

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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

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In 9 Session Treatment

3 Hr Initial Evaluation

Session I









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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.