Leigh McCullough

BRIEF PSYCHOTHERAPY OF PERSONALITY DISORDERS

Thirty-two patients with personality disorder diagnoses were randomly assigned to two treatment conditions that vary on several techniques of brief dynamic psychotherapy. Seventeen patients constituted a waiting list control group. The two brief psychotherapies showed significant improvement on target complaints, SCL-90, and Social Adjustment Scale-SR compared with the control subjects. The two therapy groups were similar in overall outcome but showed interesting differences on several subscale measures. Process measurements of videotaped sessions revealed significant variations in frequencies of therapist interventions across the two treatment conditions, which validated planned differences in the treatment techniques.

Different processes for different therapies: therapist actions, therapeutic bond, and outcome.

Therapeutic bond, as a component of the alliance, is considered a common factor in psychotherapy; however, it may operate differently in various treatments. This article investigates therapist actions, particularly affect focus, in the formation of the bond and on reduction of symptoms in short-term dynamic psychotherapy (STDP) and cognitive therapy (CT) for cluster C patients. Forty-six cases (23 STDP and 23 CT) were assessed using the Psychotherapy Process Q-Sort, the Helping Alliance Questionnaire, and the Symptom Checklist 90. These scores were used to determine (a) therapist actions that predict formation of the bond, (b) the relation of the bond to symptom reduction, and (c) how therapist actions and bond interacted to reduce symptoms. Multiple regressions were applied to the total sample and to the STDP and CT cases. Psychotherapy Process Q-Sort items describing avoidance of affects were positively related to the bond in the total sample, STDP and CT. However, the relation between therapist actions, bond, and symptom reduction differed for the two treatments. For STDP, avoidance of affect suppressed the relation of bond to symptom reduction and also negatively influenced symptom reduction. On the other hand, in CT, avoidance of affect was positively related to both the formation of the bond and to symptom reduction. Although the bond is a common factor and important component of the alliance, it appears to operate differently in STDP and CT. A focus on affect is important to the benefits of STDP but interferes with the benefits of CT.

Patient affect experiencing following therapist interventions in short-term dynamic psychotherapy

Abstract The aim of this research was to examine the relationship between therapist interventions and patient affect responses in Short-Term Dynamic Psychotherapy (STDP). The Affect Experiencing subscale from the Achievement of Therapeutic Objectives Scale (ATOS) was adapted to measure individual immediate affect experiencing (I-AES) responses in relation to therapist interventions coded within the preceding speaking turn, using the Psychotherapy Interaction Coding (PIC) system. A hierarchical linear modelling procedure was used to assess the change in affect experiencing and the relationship between affect experiencing and therapist interventions within and across segments of therapy. Process data was taken from six STDP cases; in total 24 hours of video-taped sessions were examined. Therapist interventions were found to account for a statistically significant amount of variance in immediate affect experiencing. Higher levels of immediate affect experiencing followed the therapists use of Confrontation, Clarification and Support compared to Questions, Self-disclosure and Information interventions. Therapist Confrontation interventions that attempted to direct pressure towards either the visceral experience of affect or a patients defences against feelings led to the highest levels of immediate affect experiencing. The type of therapist intervention accounts for a small but significant amount of the variation observed in a patients immediate emotional arousal. Empirical findings support clinical theory in STDP that suggests strategic verbal responses promote the achievement of this specific therapeutic objective.

Learning how to rate video-recorded therapy sessions: a practical guide for trainees and advanced clinicians.

Watching and rating psychotherapy sessions is an important yet often overlooked component of psychotherapy training. This article provides a simple and straightforward guide for using one Website (www.ATOStrainer.com) that provides an automated training protocol for rating of psychotherapy sessions. By the end of the article, readers will be able to have the knowledge to go to the Website and begin using this training method as soon as they have a recorded session to view. This article presents, (a) an overview of the Achievement of Therapeutic Objectives Scale (ATOS; McCullough et al., 2003a), a research tool used to rate psychotherapy sessions; (b) a description of APA training tapes, available for purchase from APA Books, that have been rated and scored by ATOS trained clinicians and posted on the Website; (c) step-by-step procedures on how ratings can be done; (d) an introduction to www.ATOStrainer.com where ratings can be entered and compared with expert ratings; and (e) first-hand personal experiences of the authors using this training method and the benefits it affords both trainees and experienced therapists. This psychotherapy training Website has the potential to be a key resource tool for graduate students, researchers, and clinicians. Our long-range goal is to promote the growth of our understanding of psychotherapy and to improve the quality of psychotherapy provided for patients.

The role of transference work, the therapeutic alliance, and their interaction in reducing interpersonal problems among psychotherapy patients with Cluster C personality disorders.

The aim of the present study was to examine whether transference work, the therapeutic alliance, and their interaction predicted a reduction in interpersonal problems at treatment termination. Forty-nine patients with Cluster C personality disorders from a randomized controlled trial investigating the effectiveness of short-term dynamic psychotherapy and cognitive therapy were included. Transference work was measured with the Inventory of Therapeutic Strategies (Gaston & Ring, 1992), while the therapeutic alliance was measured with the Helping Alliance Questionnaire (Luborsky, Crits-Christoph, Alexander, Margolis & Cohen, 1983). Less emphasis on transference work predicted overall reduced interpersonal problems, whereas the effects of the therapeutic alliance did not reach statistical significance. An interaction effect was also demonstrated, indicating that greater emphasis on transference work performed on patients with lower therapeutic alliance ratings was associated with a smaller reduction in interpersonal problems at termination. However, the results also indicate that a low dose of transference work may be beneficial in reducing interpersonal problems.

Short-term psychodynamic therapy as a form of desensitization: Treating affect phobias

This article presents an “anxiety-regulating” model of short-term dynamic psychotherapy that uses the behavioral principles of desensitization to treat psychodynamic conflict. In this model, psychodynamic conflict is reinterpreted as an “affect phobia.” In contrast to phobic stimuli that are external (bridges, snakes), intrapsychic phobias occur within us; the phobic stimuli are feelings. Within this framework, behavioral methods of exposure and the prevention of avoidance can be applied to avoided feelings to resolve the psychodynamic conflict. Clients who are afraid of anger, grief, or closeness are exposed to these feelings in imagery in doses they can bear. Defensive avoidance is prevented and the client experiences the conflicted feeling while learning to regulate the associated anxiety, guilt, shame, or pain. A case example with transcripted segments of sessions is presented to illustrate these principles.

Affect-Focused Short-Term Dynamic Therapy

The field of psychotherapy research is in the process of solving a great puzzle. To date, differing therapies have often demonstrated similar effectiveness, and no factors have been identified that consistently capture a large portion of the variance in improvement [1, 2]. Therapeutic alliance accounts for about 22% of the variance in outcomes [2] and patient characteristics at admission an additional 20–25% [1], leaving more than half of the variance somewhat of a mystery.

Properties of the Achievement of Therapeutic Objectives Scale (ATOS): A Generalizability Theory study

Abstract The psychometric properties of the process instrument Achievement of Therapeutic Objectives Scale (ATOS) were examined in this study. Generalizability Theory (GT) was used to evaluate variability attached to several possible sources of error. A random sample of 24 psychotherapy sessions was selected from a larger RCT trial including Cluster C patients and rated in different rating conditions (rating all scales versus rating a subgroup of the scales). Two G-study designs were used to compute variance components and generalizability coefficients. The results provided evidence that the ATOS is sensitive to differences among patients and to differences among subscales within patients (i.e., to different constructs within the ATOS). Rating condition contributed much to variability in scores when the ATOS scales were examined separately, but this variability was negligible when all scales were included in the same analysis. There was little variability due to raters, which indicates that adequately trained raters are able to apply the ATOS without contributing to measurement error.

Growth in sense of self and sense of others predicts reduction in interpersonal problems in short-term dynamic but not in cognitive therapy

Abstract Objectives: We investigated relationships between sense of self (SoS) and sense of others (SoO) and specific interpersonal problems in short-term dynamic and cognitive therapy. Method: 40 patients with Cluster C personality disorders from a RCT were included. The Achievement of Therapeutic Objective Scales (ATOS) was used to perform ratings of videotaped sessions. The Inventory of Interpersonal Problems Circumplex version was used as the outcome measure. Results: There were significant relationships between growth in SoS and SoO and reductions of hostile-dominant and hostile-submissive behaviors, as well as cold, social-avoidant and vindictive behaviors. Increase in SoO was also related to reductions in non-assertive and domineering behaviors. However, the results were only present in the STDP treatment group.

Training graduate students as raters in psychotherapy process research

The aim of this study was to conduct a further investigation of the reliability of an innovative new measure for examining processes within psychotherapy sessions, the Achievement of Therapeutic Objectives Scale (ATOS). The ATOS assesses seven common factors in psychotherapy: insight, motivation, activating affects, inhibitory affects, new learning (appropriate expression of feeling), sense of self, and sense of others. Through the use of ATOS, a patient’s degree of ‘assimilation’ or ‘achievement’ of the objectives of psychotherapy can be captured throughout the therapy process. A previous reliability study with graduate students demonstrated poor to fair reliability with 8 hours of training. This study sought to improve reliability by providing 15 hours of training in using the ATOS, in five classes of three hours, and with more focused rating. When all subscales were rated simultaneously, students (N = 32) attained ICCs in the fair to good range of.42–.71. When students were allowed to focus on two subscales at a time (rather than the full scale) during 20 hours of additional practice, ICC values increased to the range of .76–.95. The study suggests that an investment in solid training of clinically inexperienced raters may pay dividends in terms of higher quality ATOS data, and would allow individual rating of tapes.