Treating Affect Phobia: A Manual for Short-Term Dynamic Psychotherapy

Overview

This hands-on manual from Leigh McCullough and associates teaches the nuts and bolts of practicing short-term dynamic psychotherapy, the research-supported model first presented in Changing Character, McCullough's foundational text. Reflecting the ongoing evolution of the approach, the manual emphasizes "affect phobia," or conflict about feelings. It shows how such proven behavioral techniques as systemic desensitization can be applied effectively within a psychodynamic framework, and offers clear guidelines for ...
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Overview

This hands-on manual from Leigh McCullough and associates teaches the nuts and bolts of practicing short-term dynamic psychotherapy, the research-supported model first presented in Changing Character, McCullough's foundational text. Reflecting the ongoing evolution of the approach, the manual emphasizes "affect phobia," or conflict about feelings. It shows how such proven behavioral techniques as systemic desensitization can be applied effectively within a psychodynamic framework, and offers clear guidelines for when and how to intervene. Demonstrated are procedures for assessing patients, formulating core conflicts, and restructuring defenses, affects, and relationship to the self and others. Presented in an easy-to-use, large-size format, the book features a wealth of case examples and write-in exercises to help therapists build and practice key skills.
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Editorial Reviews

From the Publisher

"This work is an extraordinary synthesis of depth and practicality. It is as clear, concrete, and richly exampled a treatment manual as I have seen, yet it depicts not a simple or mechanistic therapy but one that goes to the very heart of human feeling and experience. Incorporating a profoundly integrative vision, Treating Affect Phobia will be of great value not only to psychodynamically oriented therapists but to anyone in the field who appreciates the accumulating evidence for the central role of affect--and fear of affect--in our lives."--Paul L. Wachtel, PhD, Doctoral Program in Clinical Psychology, City College and the CUNY Graduate Center, New York

"This is the training manual that teachers and practitioners of short-term dynamic therapy have been eagerly anticipating. It is the first psychodynamically oriented volume that expertly guides the novice through emotion-focused, time-sensitive psychotherapy in an explicit, step-by-step fashion. The manual is enhanced by very useful exercises that allow therapists to try out their interventions and compare them to the authors' expert responses. This volume represents a new and exciting development in the teaching, learning, and practice of psychodynamic/integrative therapy in general, and brief psychotherapy in particular."--Stanley B. Messer, PhD, Dean, Graduate School of Applied and Professional Psychology, Rutgers University

"This is a treatment manual with a number of fabulous characteristics: it takes the astute clinical observations of psychodynamic therapists and sets them within modern principles of learning and behavioral change; it draws from the best of the behavior therapy treatments for phobias; it is beautifully clear and easy to follow; and it has comprehensive learning exercises at the end of each chapter to help the clinician actually learn how to apply the treatment in clinical practice. I plan to have my students read it."--Marsha M. Linehan, PhD, Department of Psychology, University of Washington

"This carefully reasoned and researched manual starts with the simple assumption that many people are afraid of their own emotions, offers easy ways to identify whatever is being expressed or even suppressed, and explains clearly the authors' suggestions for treatment."--Donald L. Nathanson, MD, The Silvan S. Tomkins Institute and Department of Psychiatry and Human Behavior, Jefferson Medical College

The State University of New Jersey

"This is the training manual that teachers and practitioners of short-term dynamic therapy have been eagerly anticipating. It is the first psychodynamically oriented volume that expertly guides the novice through emotion-focused, time-sensitive psychotherapy in an explicit, step-by-step fashion. The manual is enhanced by very useful exercises that allow therapists to try out their interventions and compare them to the authors' expert responses. This volume represents a new and exciting development in the teaching, learning, and practice of psychodynamic/integrative therapy in general, and brief psychotherapy in particular. -Stanley B. Messer, PhD, Graduate School of Applied and Professional Psychology, Rutgers-"--The State University of New Jersey
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Product Details

  • ISBN-13: 9781572308107
  • Publisher: Guilford Publications, Inc.
  • Publication date: 1/24/2003
  • Edition description: First Edition
  • Edition number: 1
  • Pages: 365
  • Sales rank: 801,446
  • Product dimensions: 8.50 (w) x 10.90 (h) x 0.80 (d)

Meet the Author

Leigh McCullough, PhD, until her death in 2012, was Associate Clinical Professor and Director of the Psychotherapy Research Program at Harvard Medical School (Boston, Massachusetts), and a visiting professor at the Norwegian University of Science and Technology (Trondheim, Norway). She was the 1996 Voorhees Distinguished Professor at the Menninger Clinic and received the 1996 Michael Franz Basch Award from the Silvan Tomkins Institute for her contributions to the exploration of affect in psychotherapy. Dr. McCullough was on the editorial boards of Psychotherapy Research and the Journal of Brief Therapy, and conducted training seminars in Short-Term Dynamic Psychotherapy (STDP) worldwide.

Nat (Nathaniel S.) Kuhn, MD, PhD, is Clinical Instructor in Psychiatry and Assistant Director of the Psychotherapy Research Program at Harvard Medical School. He teaches STDP and supervises at the Cambridge Hospital and elsewhere. Dr. Kuhn has a private psychotherapy and psychiatry practice in the Boston area, and a Web site, www.natkuhn.com. Before going to medical school he was a mathematician.

Stuart Andrews, PhD, is a psychotherapist in private practice in Brookline, Massachusetts, and Assistant Director of the Psychotherapy Research Program at Harvard Medical School. He has presented at international conferences and conducted training seminars on STDP. He has taught and supervised clinicians and students, and published articles on psychotherapy integration and short-term therapy. Mr. Andrews is also Director of the Center for Families in Transition, where his program, "For the Sake of the Children," is mandated in a number of communities in Massachusetts for parents going through divorce.

Amelia Kaplan is a graduate student in clinical psychology at the Graduate School of Applied and Professional Psychology, Rutgers University, where she pursues interests in mind-body psychology, STDP, group therapy, and human sexuality.

Jonathan Wolf, MD, was a member of the Psychotherapy Research Program for three years. After graduating from Boston University School of Medicine, he entered the Harvard Longwood Psychiatry Residency Training Program.

Cara Lanza Hurley, PhD, received her doctorate in clinical psychology from Loyola University Chicago in 2005.

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Read an Excerpt

Treating Affect Phobia

A Manual for Short-Term Dynamic Psychotherapy
By Leigh McCullough Nat Kuhn Stuart Andrews Amelia Kaplan Jonathan Wolf Cara Lanza Hurley

The Guilford Press

Copyright © 2003 The Guilford Press
All right reserved.

ISBN: 1-57230-810-9


Chapter One

Affect and Affect Phobia in Short-Term Treatment

Chapter Objective To describe the basic concept of Affect Phobia and its importance for psychotherapy.

Topics Covered I. What Is an Affect Phobia? II. Why This Therapy Focuses on Affect III. The Definition and Classification of Affect IV. Adaptive versus Maladaptive Forms of Affect V. The Development and Treatment of Affect Phobias: An Introduction VI. The Importance of Anxiety Regulation VII. The Goals of Treatment

I. WHAT IS AN AFFECT PHOBIA?

This model of Short-Term Dynamic Psychotherapy (STDP) is based on the premise that conflicts about our feelings-what we call Affect Phobias-underlie most psychologically based disorders.

"External" Phobias

Phobias are a familiar concept to most therapists. People with phobias may fear a wide variety of external stimuli: bridges, spiders, open spaces, heights, or social situations, for example. To minimize anxiety, patients will use various behaviors to avoid them. Because these phobic stimuli are external, the phobias can be thought of as "external" phobias.

"Internal"(Affect) Phobias

Surprisingly, similar patterns can be observed in psychodynamic therapy. After watching many hours of videotape of short-term dynamic psychotherapy, it became clear to Leigh McCullough that what was conceptualized as "psychodynamic conflict" could equally well be viewed in learning theory terms as Affect Phobia-a phobia about feelings (McCullough, 1991, 1993, 1994, 1998). Since these phobias concern internal feeling states, she thought of them as "internal" phobias.

Patients Use Defenses to Avoid Affects

Just as someone with a phobia may drive miles out of the way to avoid a bridge, patients often phobically avoid the experience and expression of certain affects (feelings). One patient may avoid grief, another may avoid anger, and a third may avoid closeness. And, like patients with external phobias, patients with Affect Phobias avoid feelings by developing certain avoidant thoughts, feelings, and behaviors-referred to as defenses in psychodynamic language. A principal way that avoidant responses-or defenses-help patients avoid conflicted feelings is by keeping the feelings unconscious or outside of awareness. (However, feelings continue to have powerful effects even when they are unconscious. For example, anger, sadness, or tenderness can be building within us long before we realize it.)

Examples of Affect Phobias

A person who is phobic of being angry or assertive may instead act defensively by being silent, crying, feeling depressed, acting compliantly-or, when pushed to the limit, losing control and lashing out inappropriately. Because of the Affect Phobia, this person may be unable to respond more adaptively to their feelings of anger or assertion by setting appropriate limits.

If grief is the feared feeling, the person may choke back tears, chuckle to lighten up, or become numb and unfeeling rather than sob and get relief. People who are phobic about tenderness or caring often act tough, stay busy, or devalue others rather than open to closeness. These are just a few examples of Affect Phobias; there are many ways to defend against adaptive feelings.

To support our position that these many ways of avoiding feared affects lead to most of the problems that we encounter in outpatient psychotherapy, we turn to the subject of affect itself.

II. WHY THIS THERAPY FOCUSES ON AFFECT

Feelings Are Important Signals

Feelings carry extremely important information about people's reactions to life experiences. To dismiss this "feeling information" is to cut off an essential part of the self. Because of the importance that we place on affect, this therapy teaches patients to ask,

"What are my feelings telling me?"

Patients should treat all feelings as vital signals-not necessarily to be acted on, but always to be attended to.

Affect Has Received Less Attention Than Cognition

Both the psychodynamic and cognitive traditions have focused heavily on cognitions (thoughts), intellectual insight, and interpretation; there has been relatively little emphasis on the actual experience of affect. This is surprising, since so many patients come to therapy with problems of depression and anxiety. Indeed it may be easier to focus on cognitions because they are more consciously available. In this therapy, we attempt to shift the cognitive-affective balance by emphasizing the central and crucial role of the experience of adaptive affect in therapeutic change.

We emphasize that it is not our intent to say, "An affect focus is good, while a cognitive focus is bad." Cognition is, and always will be, a fundamental agent in therapeutic change. Furthermore, many cognitive therapists work effectively with affect (e.g., with the theory of "hot cognitions"), while many psychodynamic therapists help patients talk about affect without helping them to experience affect.

Of course, a great many patients come to therapy because of problems directly related to affect, such as depression or anxiety. But there are numerous other reasons why therapy should focus on affect.

Affect Is a Primary Motivator

In addition to symptoms such as depression or anxiety, much of the work in therapy focuses on changing patients' behavior. According to affect theorist Silvan Tomkins (1962, Vol. 1, pp. 28-87), there are three motivational systems-inner bodily sensations or feelings-that move us to act or spur specific action tendencies:

1. Biological drives (hunger, thirst, sex, etc.). 2. Physical pain.

3. Affects (anger, grief, sadness, excitement, fear, shame, joy, etc.).

As Tomkins pointed out, affects are the primary motivators of behavior, because affects amplify or intensify whatever experience they are associated with. Excitement enlivens an experience, whereas fear, shame, or disgust inhibits it. Joy will encourage participation in a task while shame can all too easily thwart it. Even though drives (e.g., hunger, thirst, sex) motivate behavior, affects can be more powerful. Consider, for example, how easily the affect shame can inhibit the sexual drive, or how the affect disgust (about being fat) can lead some individuals to refuse to eat. (See Tomkins, 1984, 1992).

If affect is the fundamental motivational force in human nature, then affect needs to be central in our clinical theory and practice, in order to have a strong impact on changing patients' behavior.

Affective Connections Can Be Changed

Tomkins also pointed out that, unlike drives, affective connections can be changed (1992, pp. 23-27). We cannot change our drives; we need to eat food and drink liquids-and our sexual orientation is fairly well fixed. But we can change what we have learned to feel ashamed or afraid of. We can learn to be proud of ourselves rather than ashamed, to be joyful about social relationships rather than anxiety-ridden, or to be interested in a task rather than angry or disgusted. We can also learn to become less afraid or less ashamed to experience our sorrow, anger, tenderness, or sexual feelings. In addition to the sense of emotional comfort or pain that affects bring, these inner signals also guide, determine, and motivate behaviors. So, to help patients understand, predict, and control behavior, it is essential to understand and alter the affective connections that lead to maladaptive or adaptive responses. Affective connections that have been "learned" can be unlearned and relearned.

Of course, "learning" means more than cognitive book learning, declarative knowledge, or intellectual insight. For behavior change, patients must experience procedural learning, or learning by doing. Patients' feelings, thoughts, and behaviors must be grounded in physically felt, bodily experience. The goal of this therapy is to give patients visceral affective experiences that will lead to "relearning" or change in maladaptive behaviors.

The fact that affective connections are learned through experience-and can be changed-makes an affect focus particularly useful and powerful for the psychotherapeutic process of changing unwanted behaviors.

Affects Are Difficult to Identify

Although affects are bodily signals that direct people's actions, they are often outside of their awareness (i.e., unconscious). Affects are therefore difficult for both patients and therapists to identify. For example, patients often say that they are unaware of increasing anger, sadness, or tenderness until it suddenly bursts forth. Thus, if inner affective signals are not sought out, brought into consciousness, and attended to, then unseen affective forces will be directing and/or maintaining patients' behaviors. Missing the presence of core motivating affects will mean that crucial therapeutic opportunities for change may be missed.

Affects Are Feared and Avoided

Feelings can often seem difficult to face, bear, or control. Not only do patients have fears of affect and tend to avoid it, but therapists often do as well. Explicitly focusing on affect in therapy can curb both patients' and therapists' tendency to move away from it. A focus on affect can also help to shape training programs to prepare therapist trainees for this extremely challenging endeavor of focusing on feelings.

Affect Has Neurological Primacy

The limbic and midbrain areas evolved before the neocortex and have been preserved relatively intact through evolutionary development. Affect appears to be generated predominantly in the limbic system and midbrain, whereas language-based thought and the modulation of affect are apparently processed predominantly in the cerebral neocortex. Although affect and cognition eventually become highly interconnected, the possibility that affect may play a more fundamental or preliminary role needs to be taken into account.

Although the limbic and midbrain systems are often devalued as "primitive," they have been preserved so well by evolution precisely because emotional processing is critical to life. A good example of this is the "conditioned fear" response (LeDoux, 1996). For survival, sensory input regarding possible threats needs to be processed as quickly as possible-a job that falls to the limbic system's amygdala. The price of this speed is accuracy: The amygdala may mistake a stick for a snake and initiate the "fightor-flight" response. The cortex takes a few extra milliseconds to process the information more discriminately, and can inhibit the amygdala's response after the fact if the snake does turn out to be a stick.

By analogy, we can speculate that interventions targeting the experience of affect will have more effect on the limbic and lower brain systems, while interventions targeting cognition will have more effect on the cortex. More purely cognitive (cortical) interventions such as coping skills may be able to inhibit immediate affective (limbic) responses, but to get to the root of the problem will require dealing with the limbic and midbrain systems, where the experience of affect is mediated.

Affect Precedes Language-Based Cognition

Just as affect preceded language-based cognition (thought) in evolution, affect and motivation emerge before language-based cognition in the development of the infant. Although cognition and affect become thoroughly interwoven as development proceeds, affect is present and predominant in the infant at birth and precedes the development of language. Stern (1985, Ch. 4) points out the significance of affective experiences in the development of the "core" self in the infant. Since affects are fundamental forces in motivating the infant and in the development of the sense of self, these profound and early affective learning experiences need to be taken into account in clinical work.

Affect Is Interwoven with Cognition

Because affect and cognition become deeply intertwined during development, both become major motivators of behavior in adulthood. Cognition plays a vital role in guiding, controlling, and selecting affect, and maladaptive cognitions are strong contributors to pathology. In addition, because of the strong relationship between affect and cognition, cognitive interventions are very effective in modifying affect and behavior. However, attending to cognition without also attending to affective experience is ignoring a fundamental motivator of behavior. In addition, we believe that a substantial portion of the effect of cognitive interventions on behavior can be attributed to the interventions' impact on underlying affect.

Throughout this book, our emphasis is on affective experience, but we also stress always attending to (1) maladaptive cognitions that block affective change, as well as (2) adaptive cognitions that help guide, support, and control adaptive affective responses.

Affect Focus Has Research Support

Finally, an increasing body of research and clinical experience shows that systematic pursuit of conflicted feelings relieves patients' suffering. Two clinical trials have demonstrated the efficacy of this therapy with Axis II Cluster C disorders and many Axis I mood disorders (Winston et al., 1991, 1994; Svartberg & Stiles, 2003). In addition, the efficacy of a focus on affect has been demonstrated in a number of process studies (reviewed in McCullough, 1998, 2000).

Summary

Although cognition (thought) has generally received more attention than the experience of affect, this model of STDP focuses on affect, for these reasons:

Affect is the primary system for motivation and therefore for change.

Affective connections that have been learned can be unlearned and relearned.

Affect is not always conscious, and thus can be easy to miss.

Affect can be difficult to face and bear, and thus is easily sidestepped if it's not addressed systematically.

Affect emerged before cognition in the process of evolution, and is processed separately and often before cognition in the brain.

Affect emerges before cognition in the development of the infant.

Focus on affect has demonstrated effectiveness in two clinical trials of STDP.

III. THE DEFINITION AND CLASSIFICATION OF AFFECT

Problems with Definitions of Emotions

Emotions are intangible and unseen, and thus harder to label than are concrete external objects. There is very poor consistency about words that denote feeling, both in languages worldwide and in writing about emotions.

Continues...


Excerpted from Treating Affect Phobia by Leigh McCullough Nat Kuhn Stuart Andrews Amelia Kaplan Jonathan Wolf Cara Lanza Hurley Copyright © 2003 by The Guilford Press. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents


Introduction

Part I. Theory, Evaluation, and Formulation

Chapter 1. Affect and Affect Phobia in Short-Term Treatment

Chapter 2. Affect Phobia, Psychodynamic Conflict, and Malan's Two Triangles

Chapter 3. Assessment and Selection of Treatment for the Patient

Chapter 4. How to Formulate a Core Psychodynamic Conflict: Spotting Affect Phobias

Part II. Defense and Affect Restructuring
Introduction to Part II

Chapter 5. Defense Restructuring Phase I: Defense Recognition

Chapter 6. Defense Restructuring Phase II: Defense Relinquishing

Chapter 7. Affect Restructuring Phase I: Affect Experiencing

Chapter 8. Affect Restructuring Phase II: Affect Expression

Part III. Self- and Other-Restructuring
Introduction to Part III

Chapter 9. Self-Restructuring: Building Compassion and Care for Self

Chapter 10. Other-Restructuring: Building Adaptive Inner Images of Others

Part IV. Diagnostic Considerations and Termination

Chapter 11. Treating Specific Diagnoses: The Relationship between DSM Diagnoses and Affect Phobias

Chapter 12. Termination

Appendix. Answers to Exercises

References

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