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by Leigh McCullough, Nat Kuhn, Stuart Andrews, Amelia Kaplan, Jonathan Wolf and Cara Lanza Hurley
Guilford Publications, 2003
Review by Lou Gallagher, Ph.D. on Sep 8th 2004

Treating Affect Phobia

Treating Affect Phobia is a sequel to an earlier work by the first author, Changing Character: Short Term Anxiety-Regulating Psychotherapy for Restructuring Defenses, Affects, and Attachment. The authors believe that much psychopathology is rooted in Affect Phobia, a fear of feelings than can be addressed by recasting the concepts of psychodynamic conflict into the language of learning theory and behavioral therapy while retaining the ideological underpinnings of Freudian analysis. Psychodynamically, Affect Phobias are viewed as a triangular constellation of defenses and inhibitory affects that block adaptive feelings; defensive behaviors  that allow the patient to avoid the conscious experience to maladaptively avoid the conscious experience of conflict between an adaptive affect; and, it’s corresponding inhibitory affect. The goal is to assist the person, within approximately 50 sessions (hence, STDP) to change their character structure to experience more adaptive affects while keeping inhibitory affects at a manageable level. As with most of the psychodynamic theoretical models, much of the action within the person takes place beyond the scope of the individual’s awareness- within the unconscious.

Organizationally, the manual is broken down into four parts. Part I focuses upon the theoretical underpinnings of the approach: how affects are developed and defined, an over-emphasis of behavioral and psychodynamic approaches to cognitions and intellectual insight rather than experiencing affect; and, how systematic desensitization may be extended to treat phobic avoidance of internal states of being. Parts II and III are devoted to the treatment of Affect Phobia through three primary treatment objectives: Defensive Restructuring, Affect Restructuring; and Self- and Other-Restructuring. The final Part discusses the application of STDP with specific DSM-IV diagnoses and the process of termination.

The manual provides numerous examples of patient-therapist dialogues which are intended to guide the clinician to become adept at identifying the core conflicts and defenses presented by the patient; and, to incorporate the techniques into their day-to-day clinical interactions.

Thomas Kuhn, in his seminal work The Structure of Scientific Revolutions, clearly articulates that paradigm shifts occur when the preponderance of evidence overwhelms the parsimony of the explanatory models used. Treating Affect Phobia is a clear example of an explanatory over-extension and over-borrowing of concepts, rather than a revision of the paradigm proper.

Fundamentally, the flaws in logic, organization, and treatment throughout the manual lead this reviewer to have serious concerns regarding the application of this approach to any patient that seeks treatment.

Some individuals may prefer to have practically every paragraph bulleted with a description of what is addressed; however, this reviewer finds it particularly distracting, confusing and redundant. Equally so are the frequent references throughout Treating Affect Phobia to the previous volume by the first author.

The authors posit, based upon a cursory review of the work of LeDoux (1996) concerning the neurobiology of affective and cognitive responses to environmental events, that parents classically condition their infants and children to become affectively phobic by excessive inhibition of the child’s affective responses. The limbic-mediated affect of the infant prior to the development of cortically based language is viewed as having dramatically negative effects upon the overall development of the individual. The extent that other individuals and social circumstances have an effect upon the individual throughout the life cycle is minimized; and, is seen as an effect of early development, rather than a system of adaptive responses a/k/a social learning theory.

In a similar vein, the authors indicate their graded exposure model of systematic desensitization is significantly different from earlier “anxiety-provoking” models using flooding, which is markedly different from what actually occurs in most clinical practices of clinicians who ascribe to a cognitive-behavioral approach. As a therapist trained in the use of Rational Emotive Behavior Therapy, an essential element is to address the central irrational thoughts (cognitions) that lead to non-productive emotional states, both inhibitory and excitatory.

Because of the power of the treatment modality that is being taught, clinicians are warned that the application of the technique is clinically contra-indicated with persons with a Global Assessment of Functioning (GAF) scale less than 50, thereby necessitating an entire chapter to the DSM-IV and assessment of the GAF. Given that the targeted audience are clinicians in practice, it is questionable whether a clinician who needs to be tutored in the either the derivation of a GAF or the structure of the DSM-IV should be practicing at all on an independent basis, without supervision.

Finally, there are a number of treatment excepts and examples that would cause this reviewer, as a Supervising Psychologist, to seriously seek legal advise from a malpractice standpoint. Take, for example, the following advice regarding “Mistaking Maladaptive for Adaptive Affects” (page 45), in which “helpless weepiness was mistaken for sadness”:

THERAPIST: My patient howled and sobbed for weeks. I thought we were really getting somewhere, but after a while, when she felt no relief and nothing changed, I realized that this was a regressive form of the feeling and wasn’t letting her function more effectively in her life. She was really feeling helpless, hopeless, powerless, and frustrated.”

The advice given in Treating Affect Phobia was “When such affects emerge, it is important to note them, explore them in a contained way, and help the patient bear them, so that the patient can come to understand the underlying meanings and the more adaptive feelings that need to be accessed.”  Reframed within a cognitive approach, the individual clearly meets the criterion of a clinical depression based upon the depressive triad (negative evaluation of current life circumstances, negative evaluation of own capacity to effect change, negative expectation for the future). For this reviewer, allowing the patient to “howl and sob for weeks” without mention of an antidepressant because it may be addressed by a fuller understanding of her misery; or, attempting to undermine the depressive triad borders on a potential lawsuit if the individual truly is a Cluster C personality that the authors indicate as a beneficiary of this treatment modality.

Rather than re-mold psychodynamic therapy, it is suggested that the reader interested in the concepts of Treating Affect Phobia receive training in Social Learning Theory, Cognitive Therapy and Behavior Therapy. Switching paradigms to scientifically-validated models rather than attempting to morph continually non-substantiated, but aesthetically pleasing, paradigms is the suggested mode of professional behavior expected of clinician-scientists.

 

© 2004 Lou Gallagher

 

Lou Gallagher, Ph.D. has a B.A. in Psychology from Hofstra University, M.S. Ed. (with Distinction) in Vocational Rehabilitation Counseling from Hofstra University, a M.A. in School-Community Psychology from Hofstra University, and Ph.D. in Clinical and School-Community Psychology from Hofstra University. Fellow, American College of Forensic Examiners. He is a NYS Certified School Psychologist and Licensed Psychologist, with training at the Institute for Rational Emotive Therapy in the early 1980’s. He has taught Psychology at Hofstra University, Long Island University and other institutions in the past. He has served for eighteen years as a Supervising Psychologist with the Suffolk County Division of Community Mental Hygiene Services where he currently supervises a number of community-based programs to divert persons with serious and persistent mental illness (SPMI) from the criminal justice systems; provide services to SPMI individuals being released from and within correctional facilities; and, coordinates disaster mental health services and the Mental Health Response Team, in addition to serving as the inoculated mental health responder for the Suffolk County Smallpox Response Team. He has been in private practice as a consulting and clinical Psychologist for twenty-one years, with an emphasis upon anxiety disorders, depressive disorders, developmental disabilities and Asperger Syndrome and forensic issues.