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What is Affect Phobia Therapy?
‘Affect Phobia Therapy (APT)’ is an integrative theory and treatment model by which patients’ problematic features can be understood, particularly cluster C personality disorders (avoidant, dependent, or obsessive compulsive PD). According to APT (McCullough Vaillant, 1997; McCullough & Andrews, 2001; McCullough, et al., 2003), affects and sense of self and others are considered to be universal phenomena that play a part in most therapies in one way or another (McCullough, Berggraf, & Ulvenes, 2010).
The Theory of APT
Activating and inhibitory affects are central for change in psychotherapy according to APT (e.g., McCullough Vaillant, 1997; McCullough & Andrews, 2001; McCullough et al., 2003; McCullough, Berggraf, & Ulvenes et al., 2010).
Activating affects are considered adaptive and include: healthy grief/sadness, closeness/ attachment, anger/self assertiveness, positive feelings for self, sexual feelings and healthy fear. While inhibitory affects are considered maladaptive and include: shame, anxiety, guilt, & pain (McCullough Vaillant, 1997).
Never the less, both activating and inhibitory affects are considered important for flexible and healthy human functioning.
Affect phobias are known as an avoidance or fear of one or several feelings (McCullough et al., 2003). More specifically, one can experience several inhibitory feelings (shame, guilt and anxiety) when one is in contact with, for example, sadness, joy or positive feelings for self. Then natural experiences feel aversive and a person will learn coping/defense mechanisms to “get away” from feelings all together (e.g. to not think about sad memories, work/eat/drink/exercise too much, rationalize, externalize and so on). Interestingly, each of the adaptive affects with their associated action tendencies can be expressed in defensive instead of adaptive ways as well (for example, the display of anger to mask sadness e.g.; Ekman, 1990; 1992; McCullough Vaillant, 1997; Tomkins, 1962; 1963).
An example of affect phobia
A friend gives unreasonable and unkind criticism, and you feel shame and anxiety (inhibitory affects) and start to cry (defensive affect). Further you apologize to your friend and even try to correct your behavior according to the friend`s preference (maladaptive defense). Instead an adaptive response would be to react with self-assertion/anger (activating affect) and in a firm way letting the other person know that you disagree, further providing a boundary by saying that you do not accept to be criticized like this again (this action is motivated by experience of positive feelings for self) and that you want to know what the friends intention is with his/her behavior. In this way the friend is provided a possibility to apologize to you, and perhaps explain what the motivation was, which might further lead to possible increased mutual understanding of each other (increase in activating feelings of closeness and compassion).
Maladaptive coping strategies/defenses can provide rewarding secondary gains (e.g., receiving help, being considered as agreeable or strong, providing a sense of independence, being in control and so forth). Unfortunately, extensive use of such maladaptive strategies comes at a considerable cost and may include a lack of intimacy, loneliness, somatic problems, lack of energy and inflexible behavior patterns.
Affect Phobias are Learned
Affect phobias are learned (conditioned) through aversive experiences, often within early relations with attachment figures, say for example being rejected when expressing need of comfort and love as a child (McCullough Vaillant, 1997).
Aversive learning patterns can inhibit later ability to be self compassionate and to feel, express and be receptive of others’ feelings like closeness, love, and trust. Over time these patterns can be rigidly established, creating a problematic sense of self and others often presented as personality dysfunctions and interpersonal problems (Berggraf, Ulvenes, Hoffart, McCullough, & Wampold, 2014).
Self-Compassion and Compassion
Within APT, self-compassion and compassion are considered to be part of affective experience and expression, and to a various degree reflect one`s quality of sense of self and others (McCullough, et al., 2003).
The construct sense of self includes aspects of adaptive self-image: self compassion, self care and value as a human being.
Sense of others involves one’s quality and pattern in how one experiences, perceives and understands other persons (McCullough et al., 2003).
Both constructs represent various capabilities to be compassionate (towards self and others) and are considered to represent broader, more stable qualities of persons (“trait” versus “state”).
Affect Phobia Treatment
Persons should be able, for example, to activate and fully experience a grief response without too much inhibitory pain; to be able to assert one’s self with less accompanying anxiety; and to feel pride in one’s self and be able to be close/loving of others without unpleasant inhibiting experience of shame or pain. Consequently, the increase in the ability to experience activating affects should influence a person's overall sense of self and others towards a more compassionate and realistic quality.
More specifically, if the therapist helps the patient experience more activating affects, the patient should develop an increased sense of self and sense of others in subsequent sessions. That is, an increase from one`s own typical activating affect levels in a psychotherapy session might lead to change in how self and others are experienced in the next therapeutic session (within person level, “state”). Thus, it might be that the experience of affects within session(s) is important for change, but it might be possible that patients’ general affective “set point” at baseline is important for how this change will develop over the course of psychotherapy.
The Current Study
We conducted a study to examine these hypotheses at session-by-session level and found some interesting results. Affects clearly play a role in the process of change in sense of self and sense of others.
Patients with generally higher levels of activating affects at the start of therapy predicted generally higher mean levels of sense of self and sense of others across therapy, whereas patients with high levels of inhibitory affects at the beginning of therapy predicted lower levels of SoS across sessions in therapy.
Experience of more than usual activating affect in a therapy session predicted increased sense of self and sense of others in their next therapy session. Within-person changes in inhibitory affects were not related to subsequent sense of self or sense of others (Berggraf, et al., 2014).
Are activating affects dealt with in similar ways-in both short-term dynamic (STDP) and cognitive therapy (CT)?
The answer is; yes and no.
The underlying processes of change seem to be similar for both therapeutic models, but the nature of the interventions and focus within sessions vary greatly.
In CT, less attention is given to the patient’s experiences of activating affects, patients’ experience of self in relation to the therapist or how the therapist is experienced within sessions.Instead, the CT therapist functions as a collaborative guide in learning how to cope better with problematic situations and emotions outside therapy, particularly focusing upon tasks and goals in therapy (e.g. difficulties in doing homework) (Beck, 1995).
In short, one could argue that CT focuses more on ‘situation outside sessions’ than ‘relation within sessions’, even though the CT theory recognizes the interdependency between the two (e.g., Safran & Segal, 1996) .
As developed by McCullough Vaillant (1997), the STDP model focuses on patients’ compassionate quality of sense of self and sense of others. In addition, there is a focus on ‘exposing’ activating affect and regulating inhibitory affects - with a particularly cautious focus on how much affect the patient can endure (‘emotional expressive and receptive capacity,’ McCullough Vaillant, 1997, p. 291). The therapist also displays an active investigating stance in how the therapist is experienced within the therapy session (McCullough Vaillant, 1997; McCullough et al., 2003a). Sessions are considered an emotional and relational “training arena” where new experiences achieved should be further generalized to relational situations outside the therapeutic context.
Our findings provide evidence that when a patient experiences more activating affects than usual in a session, it influences their quality of sense of self and sense of others to develop towards a more compassionate and realistic direction in the next session within both therapies.
How should the therapist intervene to help increase activating affects in sessions within both of the two models?
- A therapist will help to increase activating affects by several exposing techniques: Visualization, focus on emotional content in memories, pointing out patients’ signs of emotion (McCullough et al., 2003).
- Therapists’ use of confrontation, clarification and support within STDP elicited more affects than self-disclosure and information interventions (Town et al., 2012).
- Examples of therapist interventions that help patients to feel and express their activating affects are questions such as:
“What are you feeling right now while talking about being alone?” (exposing for sadness and a need for closeness/love)
“It sounds like you are being awfully hard on yourself, is there any other way you can look at this?” (confronting, supporting, exposing the patient to therapist care/compassion and probing for self-compassion).
“I just noticed the sadness in your voice and your eyes got a bit wet...it seems like you have much grief/sorrow inside which you try to hold back, what if you tried to let go for a bit…?” (empathically pointing out and exploring expression of brief affect could help the patient to deepen the experience; using enhancing words like “much grief inside” and exploring whether the patient could experience more fully the activating affect of sorrow).
- One focuses on the experience of painful problematic emotions (inhibitory affects) and then detecting attached negative automatic thoughts and their content (“When your boss said you had to do the task a bit different and you felt shameful, what did you think then?”).
- Next, the therapist typically explores what the patient did. The therapist helps the patient to see the “vicious circle” involving negative thoughts, unpleasant feeling and maladaptive actions.
- By exploring the “truthfulness” of these thoughts and eventually disconfirming this “truth”, the patient`s discomfort decreases (e.g., Beck, 1995).
- A next step in CT is then to explore alternative thought patterns (“Is there any alternative way to think about the situation?”). When the patient provides examples of comforting thoughts (“Instead of critizing me, maybe the boss wants me to learn to become even better at my job”, or, “He/she takes my work seriously”), these thoughts have great potential to elicit activating affects such as joy, closeness, and self-assertiveness/anger and so on.
- An example of how the CT therapist can provide this intervention is:
“Which feelings come up when you think of this”? (focuses more closely on the affects that are elicited by the alternative thoughts
“How does it feel like right now” (to explore the feelings)
“Do you have several feelings? Lets look at one at the time” (separate them)
“Where do you feel joy/sadness/anger in your body right now?” (increase the consciousness of where affects are felt in the body)
“Why do you think you experience this feeling with this particular thought?” (and why the affects make sense)
Summary and Conclusion
People do not often know that they avoid healthy feelings, what strategies they use and how this avoidance is related to maladaptive and often destructive treatment of self and others. Facilitation of increased experience of activating affects within a session can help a patient`s development towards a more compassionate and realistic sense of self and others in both CT and STDP. Therapists in both models can enhance their focus on activating affects by the use of various techniques, where some are mentioned in this article. In general, the therapeutic context with a therapist (an “other”) helping the patient to experience affects that feel healthy and constructive can increase the ability to receive corrective emotional experiences from others (Alexander & French, 1946; Bernier & Dozier, 2002), further increasing the ability to relate in a more adaptive fashion with others (Berggraf, et al., 2014; Schanche et al., 2011) .
Cite This Article
Berggraf, L., & Hoffart, A. (2014, November). Adaptive affects and experience of self and others in therapy. [Web article]. Retrieved from https://societyforpsychotherapy.org/adaptive-affects-and-experience-of-self-and-others-in-therapy
Alexander, F., & French, T. M. (1946). Psychoanalytic therapy. New York: Ronald Press.
Beck, J. (1995). Cognitive therapy: Basics and beyond. New York/London: The Guilford Press.
Bernier, A., & Dozier, M. (2002). The client-counselor match and the corrective emotional experience: Evidence from interpersonal and attachment research. Psychotherapy: Theory, Research, Practice, Training, 39, 32-43. doi:10.1037/0033-318.104.22.168
Berggraf, L., Ulvenes, P. G., Hoffart, A., McCullough, L., & Wampold., B. E. (2014). Growth in sense of self and sense of others predicts reduction in interpersonal problems in short-term dynamic but not in cognitive therapy. Psychotherapy Research, 24, 456-469. doi: 10.1080/10503307.2013.840401
Berggraf, L., Ulvenes, P. G., Oktedalen, T., Hoffart, A., Stiles, T., McCullough, L., & Wampold, B. E. (2014). Experience of affects predicting sense of self and others in short-term dynamic and cognitive therapy. Psychotherapy, 51, 246-257. doi: 10.1037/a0036581
Ekman, P. (1992). An argument for basic emotion. Cognition and Emotion, 6, 169-200. doi: 10.1080/02699939208411068
Ekman, P., Davidson, R. J., & Friesen, W. V. (1990). The duchenne smile: Emotional expression and brain physiology II. Journal of Personality and Social Psychology, 58, 342-353. doi: 10.1037/0022-3522.214.171.1242
McCullough Vaillant, L. (1997). Changing Character: Short-term anxiety-regulating psychotherapy for restructuring defenses, affects, and attachment. New York: Basic Books.
McCullough, L., & Andrews, S. (2001). Assimilative integration: Short-term Dynamic Psychotherapy for treating Affect Phobias. Clinical Psychology: Science and Practice, 8, 82-97. doi: 10.1093/clipsy.8.1.82
McCullough, L., Berggraf, L., & Ulvenes, P. (2010). The Affect Phobia as a Unifying Theory of Change across Theoretical Orientations. Symposium in Florence arranged by Society of Exploration of Psychotherapy Integration (SEPI).
McCullough, L., Kuhn, N., Andrews, S., Kaplan, A., Wolf, J., & Hurley, C. L. (2003). Treating Affect Phobia: A manual for short-term dynamic psychotherapy. New York: Basic Books.
Safran, J., & Segal, Z. V. (1996). Interpersonal process in cognitive therapy. Jason Aronson, Incorporated.
Schanche, E., Stiles, T. C., McCullough, L., Svartberg, M., & Nielsen, G. H. (2011). The Relationship between Activating Affects, Inhibitory Affects, and Self-Compassion in Psychotherapy Patients with Cluster C personality Disorders. Psychotherapy, 48, 293-303. doi: 10.1037/a0022012
Tomkins, S. (1962). Affect, imagery, consciousness: Volume I, the positive affects. New York, Springer Publishing Co.
Tomkins, S. (1963). Affect magery consciousness: Volume II, the negative affects. New York, Springer Publishing Co.
Town, J. M., Hardy, G. E., McCullough, L., & Stride, C. (2012). Patient affect experiencing following therapist interventions in short-term dynamic therapy. Psychotherapy Research, 22, 208-219. doi:10.1080/10503307.2011.637243
Vaillant, G. E., & Drake R. E. (1985). Maturity of ego defenses in relation to DSM-III Axis II personality disorder. Archives of General Psychiatry, 42, 597-601. doi:10.1001/archpsyc.1985.01790290079009