What constitutes a desensitized non-emotional person
Affect phobia therapy
The central treatment principles of APT are (McCullough et al. 2019) to help the patient
to be able to experience and adaptively express the full spectrum of one's feelings;
To have compassion for oneself and for others;
to find a healthy balance of autonomy and dependence and
make the treatment as efficient as possible.
The therapeutic attitude is characterized by a partnership relationship at "eye level" and the emphasis on the patient's will to cooperate as well as the active processing of the defense in contrast to free association in order to prevent malignant regressions and the development of a transference neurosis. Behavioral therapists will also find much of this therapeutic stance in the “cognitive behavioral analysis system of psychotherapy” (McCullough 1984).
The APT belongs to the STDP family. However, “short term” is not to be equated with the term “short term” in the psychotherapy guidelines. The typical session duration is 50 minutes with a frequency of one to 2 sessions per week. The APT treatments last as long as necessary. Depending on the complexity of the disorder, treatments can extend over 100 hours or more. The APT is suitable for the entire spectrum of mental disorders; there are no disorder-specific contraindications (McCullough et al. 2003, 2019). The manual is process-oriented. The interventions respond to the clinical phenomena that are structured using the conflict and person triangles (Fig. 1).
Importance of affects
In the following, the terms affect, emotion and feeling are largely used synonymously. In APT, affects are the focus of therapy because mental disorders are viewed as a result of affect phobias (McCullough et al. 2019). Affects are considered to be the primary motivational system in humans (Demos 2019; Grecucci et al. 2017; Tomkins et al. 1995). Affects provide orientation. They represent a kind of inner compass. To perceive them means to be in contact with the inner voice, to feel alive. Being able to adaptively express affects is a prerequisite for successful social relationships (McCullough et al. 2019; McCullough Vaillant 1997). During treatment, patients are continually instructed to become aware of their own feelings. This means, firstly, to feel them in the body, secondly, to name them correctly and, thirdly, to become aware of the associated impulses for action. Even if the APT regards it as essential to be able to feel all feelings, it is not about blindly following feelings or acting them out, but rather becoming aware of the inner emotional world in order to be able to make adaptive decisions. Because you can only regulate what you are consciously aware of.
Since the differentiation between adaptive and maladaptive affects is important for the expression of affects, McCullough et al. (2003, 2019) worked out corresponding criteria. Important differentiating criteria are the consequences of the affect expression and the physical experience of the affect. An adaptive affect can be perceived in the body; its expression is liberating and represents a healthy reaction. Maladaptive affects are in the service of defense; the expression is interpersonal destructive and increases misunderstandings, loneliness and hopelessness. For example, tears or the word grief can represent a maladaptive defense. The distinction can be clarified by exploring the physical experience and the ideas associated with it. Real tears and real grief are, if painful, ultimately liberating and strengthen the bond. Maladaptive tears often hide anger and stand for a position of self-tormenting helplessness and hopelessness or reflect massive self-criticism. These tears increase the agony, do not have a liberating effect and do not represent a progressive therapeutic event, but are in the service of defense and maintain the patient's disturbance.
Conflict triangle and person triangle
The conflict triangle describes the psychodynamics of the symptoms, the person triangle describes the emergence and maintenance of maladaptive reaction patterns in primary and current relationships (Fig. 1).
In the conflict triangle, symptoms are understood as a consequence of the defense against adaptive affects (e.g. anger, love, sadness, positive self-esteem, sexuality), which became conflictual in the individual development history and therefore trigger fear and defense (Vaillant 1997). The conflict triangle thus represents a derivation of Freud's second fear theory, whereby the function of the “instinctual impulses” has been replaced by that of the affects (Freud 1991; Vaillant 1997). The application of the conflict triangle is shown in case study 1.
Case study 1 application of the conflict triangle
patient: I told my colleague that it is not right for me that he is taking another bridging day and that I am going away empty-handed again (anger / self-assertion ≙ adaptive feeling), but then I suddenly felt insecure (fear [A-Pol im Conflict triangle]), I was embarrassed (fear of shame and defense in the form of self-judgment and projection of the judgment), and I backed down (defense: avoidance, submission).
Explanation: In this short vignette, anger represents the averted adaptive feeling (F-pole in the conflict triangle), which moved the patient to assert himself briefly against his colleague. However, the mobilization of anger was followed by fear (A pole in the conflict triangle) and then the defense (D pole in the conflict triangle) in the form of self-criticism, projection of criticism onto others and submission in motion. The defense causes the maladaptive symptomatic behavior.
Affect phobias develop in the relationship with the primary caregiver, because feelings are always associated with relationships and relationship experiences (Bowlby 2010; Vaillant 1997). This is made clear in the person triangle. Affect phobias are learned or conditioned in the primary relationship experiences (P, "past persons" [people of the past]) and lived out in today's relationships (C, "current persons" and T, "transference")) .
In this model, people are born as infants unencumbered by neurotic conflicts and are competent in expressing their feelings to let the other person know what they want. They scream when something doesn't fit and don't stop until their parents figure out what they need. Unfortunately, children also learn that expressing certain feelings carries the risk of losing the “love” of the primary caregiver, which triggers fear. The affect later automatically evokes fear and the corresponding defensive behavior via the conditioning process (McCullough Vaillant 1997; Vaillant 1997). In a healthy development there is no massive fear of their own feelings, but rather the child learns to regulate emotions on the basis of a secure attachment (Fonagy et al. 2010; McCullough et al. 2019).
The APT distinguishes between 3 categories of interventions, which are used depending on the therapeutic process and the functional level of the patient. The conflict triangle provides orientation about the process. The therapist checks whether defense, fear or the adaptive affect / impulse is in the foreground and adjusts his interventions accordingly.
The interventions aim to help the patient to become aware of his defenses, i.e. That is, to recognize the defense, including its destructive consequences, to give it up and replace it with healthier reactions (case study 2). In behavioral therapy language, these would be response prevention interventions.
Case study 2 for the restructuring of the defense
P: (Patient averts his gaze, looks at the floor for a long time while he is speaking.)
T: Do you notice averting your gaze while speaking to me [Marking Defense Against Emotional Proximity]? What would happen if you looked at me? Do you want to give it a try? [Defense challenge].
T: What are the main problems you seek my help for?
P: I'm done, I have run out of energy, and nothing has made me happy since my wife left me 6 weeks ago. She just moved out and lives with another man.
T: How did you feel that your wife left you?
P: I don't know [Defense: helplessness or avoidance of emotional closeness] -‑-- (short silence), I think I'm such an idiot [Defense: turning against the self].
T: If you call yourself an idiot here, there is something hurtful about it, as if you are hurting yourself [reflection of the defense]. If you did not attack yourself, how would you feel about your wife in response to being abandoned?
Restructuring of affects
These interventions aim at reducing the fear of and experiencing the previously conflicting affects. The first step is to fully experience the affects and the second step is to express them appropriately. The full experience of the affects corresponds in the language of behavior therapy to exposure to the phobic stimulus. The gradual exposure of the fear-inducing affects in a secure relationship with simultaneous blocking of the defense or avoidance behavior and the regulation of the fear that arises leads to desensitization of the phobic affect. This affect no longer scares the patient and therefore no longer needs to be warded off, but is available to him again (McCullough and Osborn 2004). For desensitization to be successful, it is necessary for the patient not only to talk about the feelings, but to experience them fully (i.e. correctly name the affect, feel it in the body and describe the associated impulse to act). Prerequisites for this type of intervention are adaptive conceptions of oneself and objects as well as, closely related to this, sufficient ability to control impulses. The restructuring of affects is about internally experiencing and examining every feeling in a safe space, gradually increasing the intensity of the feeling depending on the affect tolerance. Very intense aggression, even if triggered by people in the present, comes from early childhood emotional injuries. Experiencing these emotions with full intensity then usually brings memories of this time to light. In case study 3, for example, the friend's face could be transformed into that of a parent.
Case study 3 for the restructuring of affects
T: You say that made you angry. How do you feel the anger in your body? [T focused on the physical experience of the emotion].
P: (straightening up in the chair and clenching his fists) There is a feeling of heat in the stomach that boils up [psychomotor skills and introspection of the patient show that he can experience the anger physically without experiencing excessive fear].
T: What impulse is associated with anger? How would you, if there was only this anger and nothing to hold it back, how would you, in your fantasy, let all the anger hit the woman with full force? [The therapist now focuses on the impulse to act associated with the affect of anger. This is possible because the patient can experience the affect of anger internally on the basis of a secure relationship with the therapist.].
P: (in a firm voice, clenching fists and with implied punches) I would hit her in the face again and again until the face is a bloody pulp, until she is dead [experiencing the action impulses of unconscious murderous anger without symptoms of fear].
T: When you look the corpse in the eyes, what color are the eyes, who do you see?
P: My mother (‑-- starts to sob).
Restructuring of self and object ideas
These interventions are structural and aim to build self-care and compassion for oneself and improve relationship skills. They always also include the processing of primitive, reality-distorting defense mechanisms such as projection, turning against the self and division, as well as interventions for restructuring the affects, such as experiencing loving feelings (pride, interest, closeness, care) for oneself and others. Typical interventions for the restructuring of self-conceptions aim at the recognition of one's own worth, one's own strengths and limits, perception and responsiveness to the signals of one's own body, the ability to care for and assert oneself in order to be able to pursue one's own needs (case study 4).
Case study 4 interventions for restructuring self-imagination
T: Can you imagine listening to the story you just told me on the radio? How would this story make you feel about the person who went through all of this [change of perspective]?
P: Hm ... I would be sad and comfort her.
T: Can you empathize with yourself now and here? [Exposure to positive feelings about self].
P: No, I feel stupid, I would consider myself arrogant. [Defense].
T: So, when it comes to accepting and loving yourself, then you feel stupid and arrogant. Are you aware that you are devaluing yourself when it comes to accepting and valuing yourself? [Awareness of the defense].
T: What is happening in your body [anxiety regulation intervention] as we talk about devaluing yourself instead of treating yourself with compassion and appreciation?
P: I feel tense [afraid].
T: Yes, it scares you, and something tenses up in you [A, fear pole], you consider yourself stupid and arrogant [D, defense] instead of accepting each other and treating each other with compassion and appreciation [F, adaptive emotion]. That sounds painful. [Formulation of the central conflict with the conflict triangle].
P: That's it too.
T: Do you want to change it? Do you want to learn to be compassionate and loving towards yourself? [T motivates the patient to oppose the defense].
P: Yes, that's why I'm here. I'm too hard on myself and expecting too much. I am exhausted and burned out.
T: Let's start by figuring out what is absolutely the worst that can happen to you when you show compassion and appreciation for yourself. [Exploration of fear and defense].
For the restructuring of the conception of objects, it is examined how the patient perceives other people, including the person of the therapist (case study 5). This is v. a. necessary for problems with intimacy, emotional closeness and relationship problems. Little can be achieved in therapy if a patient cannot allow trust and sympathy in the therapeutic relationship. Treatment goal is a mature, well-integrated self that can strike a healthy balance of autonomy and connectedness with others.
Case study 5 for the restructuring of the object presentation
P: You seem as cold and distant to me as my father (in an irritated voice)! [Transfer, at the same time projective anger].
T: That sounds very uncomfortable. Can you tell me how it comes that you perceive me like that? [Examination of object perception and reality check].
P: You just ask and don't tell anything about yourself.
T: Yes that's true. But I wonder if you can think of any other reasons for my behavior than that I'm out to be cold and aloof with you? [Intervention to improve reality check].
P: (nods) I know you are a therapist, this is about me.
T: Is it all right for you if we now examine the feelings that are triggered in you when I appear “cold and distant like your father”? [After the patient can cognitively differentiate the therapist from the father transference, it becomes possible to examine the feelings that are triggered by it. Only the processing of these feelings will enable the patient to build up a more realistic object perception.]
Process instruments were developed for the APT with which video sequences of the therapy sessions are evaluated and which can be used in process research and training if required: The progress of the patient is assessed using the “Achievement of Therapeutic Objectives Scale (ATOS)” rating scale ( Ryum et al. 2014a, 2014b; Valen et al.2011): How well the patient recognizes his maladaptive reaction patterns (defense), the extent of his motivation to stop this maladaptive behavior, the mobilization of the defended affects, the extent of fear, the degree of adaptive behavior are assessed on a scale from 1 to 100 (e.g. self-opening, relief) as well as the quality of self-image and object perception or perception (e.g. division and compassion). Several empirical studies have shown the reliability, validity and usefulness of ATOS (Berggraf et al. 2014a, 2012; McCullough et al. 2011; Ryum et al. 2014b; Town et al. 2012; Valen et al. 2011). For example, the ATOS was able to show how insight correlated positively with the treatment result (Kallestad et al. 2010). Another process study with the ATOS showed that the extent of the emotional experience correlated with the restructuring of self and object perception. The deeper the emotional experience, the more compassionate and realistic the self and object perception became (Berggraf et al. 2014b). Analogous to the ATOS, Osborn designed another scale in order to assess the therapist's interventions in the sense of an adherence scale (Donovan et al. 2016; Tab. 1): On a scale from 1 to 100, the therapist assesses how well the therapist is maladaptive ( Defense) and makes the patient aware of how well it promotes the patient's motivation to stop maladaptive behavior, to what extent it promotes the experience of affects, conveys insight, regulates fear and restructures self and object perception (Table 1) .
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