Learn to Evaluate Therapy Tapes in a Few Easy Steps by dalmatian


									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
Defense             Anxiety

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

Universal Principle of Psychodynamic
   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
                Affect Phobia
   Psychodynamic conflict arises during
    development by a process of classical
   Adaptive affect (F) is paired with excessive
    inhibition (A)
   This can be viewed as “Affect Phobia”: a phobia
    about feelings
       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
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
   Sessions divided into 10 minute segments
   For each segment, the core affective conflict is
   Achievement of each objective is rated 1-100
             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
    The ATOS as a Learning Tool
   ATOS is also a helpful learning tool for learning
   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
          7 Treatment Objectives
 (in Common Factors and STDP terminology)
1)   Awareness or Insight of maladaptive behaviors (Defense
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
          (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
        (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 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
               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
            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.
       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)
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¨
               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
                   In 9 Session Treatment

3 Hr Initial Evaluation   Session I   II   III   IV   V   VI   VII   VIII IX
       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.

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