Theoretical Reinforcement

‘Leigh McCullough is among psychology history’s most unifying and underestimated theorists. And we had her among us. Leigh died of ALS in 2012.’

Jørn Hokland
March 1, 2021

In the last post, Hillestad criticizes those who claim reinforcement as the only explanation, ie as a one-factor explanation. I agree with this critique, but in the same epistemological ditch we find many of the school fathers of psychology; the clinging to The one principle by which all other (s) principles can be reduced or dissolved. To put it bluntly – Skinner reduced Piaget’s development to reinforcement, just as Piaget reduced reinforcement to development, and Freud reduced free will to deterministic drive, as May dissolved psychological causality in the great freedom. The pattern is the school father who admittedly reveals one important psychological factor, but who at the same time shows a divisive need to claim that all other (s) basic factors are wrong. Hillestad is therefore right that psychology needs a multi-factor theory. But he gives the impression that no one has succeeded in this. Then Hillestad forgets the theorist at Harvard Medical School, also Professor II at NTNU and head of research at Modum Bad – not a divisive school father, but a unifying woman: Leigh McCullough.

It turned out to be valuable that McCullough was already trained in behavioral therapy when she began her apprenticeship with psychoanalyst Habib Davanloo. By studying his patient videos, Davanloo had found that defenses can be effectively detected and blocked, so that the patient in connection with his therapist experiences intense breakthroughs to repressed emotions and memories, with rapid symptom relief as a result. When McCullough saw and learned this, psychoanalysis merged with behavioral therapy: Attachment feelings are the phobic object, defenses are evasive responses, and Davanloo’s ISTDP is at its core exposure therapy with response prevention (in itself a revolutionary method discovered by another woman, Mary Cover Jones, also known as the mother of behavioral therapy).

With the affect phobia theory, Leigh McCullough contributed to a learning-theoretical reformulation of psychoanalytic theory: Sigmund Freud’s anxiety theory (that unconscious emotions trigger anxiety that drives defense against emotions), Anna Freud’s ego psychology (about defense diversity), Bowlby’s attachment theory (which expands Sigmund’s effective method. In addition to affecting phobia formulation, McCullough alleviated ISTDP by down-regulating intense anxiety with CBT interventions, and in the book Treating Affect Phobia (McCullough et al., 2004), she removed the I from ISTDP. In Changing Character (1995) she also went a long way in an intertheoretical reduction of Malan’s conflict triangle (Freud’s anxiety theory) to learning theory: first that emotions learn to trigger anxiety through Pavlovian conditioning (trigging that can be desensitized by Jonesian exposure),

The only thing Changing Character seemed to lack as a complete multi-factor theory, and which Leigh discussed during his stay at NTNU in the early 2000s, was a cognitive theory for the formation of the inner structure of the defenses. Here she showed interest in Piaget’s studies of children’s cognitive development, especially that learning of objects and causality are inextricably intertwined. Causal texture was already explored by Tolman and Brunswik as strategy learning, and what else is defense than causal strategies for avoidance and achievement? Leigh McCullough had a rare ability to find and collect the gold nuggets from the scattered gravel roofs of psychology.

Anyone who had the pleasure of watching Leigh do therapy knows with what warmth and respect she met the patient. In book form, the humanistic in short-term dynamic therapy is well expressed in Jon Frederickson’s Co-Creating Change (2013), where the patient is repeatedly given the choice between either using their habitual but now conscious defense, or knowing the emotional somatic component and impulse and becoming free – an existential choice.

Leigh McCullough’s original contribution does not lie in the specific interventions – here, like eclectics, she picks up freely from the toolbox. And with modern ISTDP adaptations for fragile and high-resistance patients, this is a more complete model than Leigh’s STDP. But both ISTDP and eclecticism etc. lack deep theoretical integration: Leigh left behind an ingeniously simple multi-factor explanation that gathers most of the basic principles our school fathers divided the subject into. And we had her among us. Leigh died of ALS in 2012.

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Short-Term Psychodynamic Psychotherapy

By Allen Eppel

This book is an easy-to-use guide to short-term psychodynamic psychotherapy for early career practitioners and students of mental health. Written by an expert psychiatric educator, this book is meticulously designed to emphasize clarity and succinctness to facilitate quality training and practice. Developed in a reader-friendly voice, the text begins by introducing the theoretical underpinnings of psychodynamic psychotherapy. Topics include the principles of attachment theory, the dual system theory of emotion processing, decision theory, choice point analysis and a critical review of the research literature. The book then shifts its focus to a description in a manualized format of the objectives and tasks of each phase of therapy within the framework of the engagement, emotion-processing and termination phases. The book concludes with a chapter on psychodynamically informed clinical practice for non-psychotherapists.

Short-Term Psychodynamic Psychotherapy is the ultimate tool for the education of students, residents, trainees, and fellows in psychiatry, psychology, counseling, social work, and all other clinical mental health professions.

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The Client Who Changed Me: Stories of Therapist Personal Transformation

By Jeffrey A. Kottler, Ph. D., Jon Carlson, Psy.D., Ed.D.

Although the impact that clients can have on therapists is well-known, most work on the subject consists of dire warnings: mental health professionals are taught early on to be on their guard for burnout, compassion fatigue, and countertransference. However, while these professional hazards are very real, the scholarly focus on the negative potential of the client-counselor relationship often implies that no good can come of allowing oneself to get too close to a client’s issues. This sentiment obscures what every therapist knows to be true: that the client-counselor relationship can also effect powerful positive transformations in a therapist’s own life.

The Client Who Changed Me is Jeffrey Kottler and Jon Carlson’s testimony to the significant and often life-changing ways in which therapists have been changed by their patients. Kottler and Carlson draw not only upon their own extensive experience – between them, they have more than fifty years in the field – but also upon lengthy interviews with dozens of the country’s foremost therapists and theorists. This novel work presents readers with a truly unique perspective on the business of therapy: not merely how it appears externally, but how practitioners experience it internally. Although these stories paint a complex and multi-layered portrait of the client-counselor relationship, they all demonstrate the profound and unexpected rewards that the profession has to offer.

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Psykoterapi – De sex grundläggande kompetenserna

Författare: Leif Havnesköld, Birgitta Elmquist

Denna bok handlar om psykoterapi. Den skiljer sig dock från många andra metodböcker i ämnet genom att den inte utgår från en specifik inriktning, metod eller skolbildning. I stället beskrivs sex empiriskt grundade kärnkompetenser som, oavsett inriktning, är gemensamma för det goda kliniska arbetet. Boken presenterar dessa kärnkompetenser och hur de kan utvecklas under hela den psykoterapeutiska karriären. De handlar om:• att kunna tillämpa en teoretiskt övergripande, sammanhållen förklaringsmodell för personlighetsutveckling • och psykopatologi• att kunna skapa och bevara en god terapeutisk relation• att ha en modell för klinisk bedömning och konceptualisering • att genomföra själva behandlingen och att använda strategier och interventioner• att kunna avsluta och evaluera behandlingen• att vara medveten om intersektionalitet samt kulturella och etiska aspekters påverkan i psykoterapi.Psykoterapi – de sex grundläggande kompetenserna riktar sig till blivande psykoterapeuter under olika faser av sin utbildning i psykoterapi, blivande psykologer samt till kliniskt verksamma psykologer och psykoterapeuter. Den kan också fungera som stöd och inspiration för lärare och handledare i psykoterapi.


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Can Robots Train Therapists?

Furhat Robotics

Psychotherapy is a notoriously hard discipline to practice and perfect due to a lack of ‘standardized patients’. Robert Johansson, Associate Professor of Psychology at Stockholm University is convinced Furhat is the perfect solution to this problem. With the unparalleled expressivity and conversational capabilities of the Furhat platform, Robert plans to build several virtual standardized patients that can be used to train therapists.

Read more about Robert’s vision – and how robots can help us understand human suffering

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Dr Jonathan Egan and the Journey of Returning to the Self!

From the Therapy Talks Podcast

Show Notes:
Chris talks to Dr Jonanthan Egan about fearing our emotions, the Therapy model Affect phobia and how we can return to the world of living from defensive holding and avoidance of feeling.  He brings a wealth of invaluable experience to the conversation and looks at the challenges of burnout for therapists and how we can move beyond this. A fascinating and insightful conversation.

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The Art of Living Virtually – For Now

By Kristin Osborn

As a student of self-care, I’ve identified what works for me and I’ve integrated it into my daily schedule. After weeks of isolation due to the pandemic, here are four activities that have helped :

  • Taking walks
  • Developing a daily schedule with set breaks
  • Allowing time to experience my emotions
  • Connecting with others.

Una McClusky, author of Transference and Countertransference from an Attachment Perspective, stresses the importance for care providers to connect with others. I’ve taken her message to heart, integrating as many moments of connection into my daily routine. Previously, I might have shied away from the ringing phone, hoping to hold onto some silence in the middle of a busy schedule. Now I’m encouraging myself to move forward, pick up the phone, and connect.

Recently, I converted a 2-day workshop into a virtual conference. A resulting benefit was that it opened up ongoing communications with psychiatry residents, psychotherapists, nurses, physicians and students from around the world.

I also taught an online course with psychiatry residents at UC San Diego — the Basics of Affect Phobia Therapy. I felt it was essential not only to demonstrate how these principles can be used with their patients, but also with themselves to experience less anxiety and more connection.

Launching an online community

A few weeks ago, we launched Therapist Affect Phobia Community — a weekly online forum which provides a way for mental health professionals to exchange observations, learn from one another, receive support and connect. Dr. Michael Alpert, a psychiatrist from NYC, joined me as a guest one week. He explained why it can be difficult seeing our faces online, then demonstrated a technique we can use remotely at home. To practice this exercise, you’ll need to look at your reflection in the mirror, or through your phone/computer. As you look at yourself, pay close attention to your eyes and ask yourself these questions:

  • What are you noticing as you see yourself?
  • Can you accept what you are seeing?
  • What could be a barrier to accepting yourself?
  • What feelings are you experiencing toward yourself?
  • When have you felt like this in the past?

I volunteered to help Dr. Alpert demonstrate this technique then looked at my face on the Zoom video window. Immediately I noted the tiredness in my eyes. I explained that I felt as though I looked older, wiser and concerned.

Dr. Alpert asked me to pay attention to my tiredness. I felt tears come to the surface and I experienced sadness. He asked me if I was feeling more compassionate toward myself, but instead, my sadness deepened. I realized I was experiencing loss. I was missing what was familiar — my offices, my clients, my friends, my colleagues and I was feeling worried — worried about finances, my well-being and not knowing what life will look like post-pandemic.

After our forum ended, I noticed that I was teary at times and experienced discomfort. The next morning, I experienced separation anxiety with my trainees online and felt deeply sad at the loss of our in-person connection.

However, it’s important to note, that while connecting with one another, we were all feeling more alive, less tired.

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The Science of Giving Thanks: A Proven Win-Win

By: Kristin A. R. Osborn & Dr. Maneet Bhatia, Ph.D. (Harvard Medical School) — Contributing Editors to The THX Co. Journal

Are people inherently self-interested or altruistic?

The answer based on scientific research is, we are both.

Humans want to grow, excel, succeed and survive. This means in many cases, we need to be competitive, and battle over limited resources and opportunities. However, what research continues to demonstrate is, despite these natural tendencies, humans are driven towards being altruistic and giving.

Neuroscientist, Dr. Jordan Grafman, has investigated the origins of empathy and generosity in the human brain by conducting fMRI (functional magnetic resonance imaging) scans of subjects’ brains while they had an option to donate or not donate to charity. fMRI scans measures brain activity by detecting associated changes in blood flow. When we carry out certain tasks, different areas of the brain become active and engaged.

What did he find?

Interestingly, in this study, donating to a charity (being generous), triggered activity in the same parts of the brain that light up when we crave certain foods or engage in sex.

In other words: we are hard wired to be generous and giving — AND it feels good too.

In the field of psychology, we refer to one’s ability to give and receive as ‘Receptive Capacity.’ Receptive Capacity measures a person’s ability to provide and receive caring from others, to experience both positive and negative emotions in a healthy manner, to feel empathy and perceive others with accuracy and compassion while also seeing oneself as worthy of care.

It is this Receptive Capacity that mental health professionals’ work to instill and cultivate in their patients. Research shows that when patients are able to build this capacity, it strengthens their compassion for themselves and others, reduces maladaptive and negative emotional reactions, and increases adaptive and healthy expression of emotions and their overall emotional well-being.

Ultimately, people are able to live more authentic, genuine, and purposeful lives (e.g., Bhatia, et al, 2009; McCullough et al, 2003).

In all industries, be it health, corporate, or education, management leaders are implementing research from organizational psychology that identifies “giving” as an important and rewarding component in developing group cohesion and productivity. Whether giving your time to help a student learn new concepts and skills, or sharing ‘war stories’ of building your own company with aspiring entrepreneurs, it is in these moments of giving where we reap lasting benefits.

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An Intimate Letter to My Community Dealing with the Pandemic by Kristin Osborn

As a student of self-care, I’ve learned the importance of identifying what works and integrating it into my daily schedule. After three weeks of isolation, I’ve discovered that experiencing my emotions, following a schedule with set breaks, walking and connecting with others is what works-for now.

I learned from Una McClusky, author of Transference and Countertransference from an Attachment Perspective, how important it is for care providers to be in connection with others and I’ve taken that to heart, integrating as many moments of connection possible with my colleagues into my week. In the past, I might have shied away from the ringing phone, hoping to hold onto some silence in my busy days, but now I’m encouraging myself to move forward, pick up the phone, and connect.

Since my 2-day virtual conference that was supposed to take place in Los Angeles, I’ve had the privilege of working with psychiatry residents, psychotherapists, nurses, physicians and students from Canada, Denmark, England, Ireland, Italy, Norway, Sweden and the US.  On March 26, I taught the basics of Affect Phobia Therapy to psychiatry residents at UC-San Diego online. I felt it was essential not only to demonstrate how these principles can be used with their patients, but also with themselves so they could experience less anxiety and more connection. On March 30th, The Stockholm Certified APT™-Core Training met with trainees from Sweden, Norway, Denmark and Italy to ‘check in’ about how they are doing both professionally and personally. On April 3rd, I met with students from SAPU in Stockholm remotely and we discussed the importance of processing feelings of loss throughout the course of treatment, not just at the end.

In addition, I hosted our 2nd Therapist Affect Phobia Community Hour with guest, Dr. Michael Alpert of NYC. He explained why it can be difficult seeing our images online and demonstrated a technique anyone can use at home by themselves or with another person. To practice this exercise, you’ll need to look at your reflection in the mirror, or through your phone/ computer screen. As you look at your image, pay close attention to your eyes and begin to ask yourself questions like:


What do you see?

 What are you noticing as you see yourself? 

Can you accept what you are seeing? 

What does it feel like to accept yourself? 

What’s getting in the way of you accepting yourself? 

What feelings are you experiencing toward yourself? 

When did you feel like this in the past? 


I volunteered to help him demonstrate this technique and followed his directions to look at my image on the Zoom platform. Immediately upon looking at my image I noted the tiredness in my eyes, I felt I as though I looked older, wiser and concerned.

When he asked me to pay attention to my tiredness, I felt tears come to the surface and I experienced sadness. He asked me if I was feeling more compassionate toward myself, but my sadness deepened instead. I realized that I was experiencing loss, I was missing what was familiar to me, my offices, my clients, my friends, my colleagues and then I noticed that I was feeling worried too, I was worried about finances, my well-being and not knowing what life will look like when the pandemic ends. My feelings went deep during his demonstration and at a certain point, I became self-conscious and retreated from the demonstration to resume my role as host. I shifted my gaze from my own reflection and looked at the square boxes in front of me with the names and faces of mental health clinicians and researchers from all over the world.

After our Therapist Affect Phobia Community Hour ended, I noticed that I was teary at times, experiencing discomfort and becoming more aware of my losses. The next morning, I experienced separation anxiety with my trainees while having to meet them online and felt deeply sad for only seeing them through a computer because of our loss in ability to be with  each other in person. However, it’s important to note we all noticed that while we were personally connecting with one another, we were feeling more alive, less tired.

After our meeting, I joined a live stream yoga class and felt a deep longing for the comfort and warmth of my local studio, reluctantly adjusting to doing yoga at home. When my instructor asked us to name an intention for the class, I became acutely aware and distracted by an overwhelming sense of loss that settled inside of me as I realized I was far away from many meaningful people in my life and worried that I may never see some of them again.

Tears come to my eyes and I remembered the last time I felt this way was in August 2010 when I visited Leigh McCullough in San Diego before she completely lost her capacity to talk due to ALS. I remembered her weeping in my arms, deeply in touch with her sense of loss, loss of what was and loss of what was coming. Her capacity to experience the depths of her emotions was profoundly touching and I witnessed a ‘letting go’ happen inside of her followed by a sense of relief as she experienced her feelings with me.

As I remembered these memories of Leigh, I felt an old sadness rise to the surface and I grieved for that time long ago.  I realized that once again, I was explicitly aware of change in motion, not only experiencing it, but also witnessing the end of what was once before. A long time ago, I learned that the only option in these moments is to master a level of acceptance, acceptance of what is now.

Structure helps me show up and accept what is happening right now. It’s my answer to any problem, it keeps me accountable and enables me to work toward the goals that are important to me. What is difficult about the pandemic is that all of us are in a free fall together and we have to adapt to our circumstances as they arrive. When you create a structure of self care, it will eventually turn into a system. So it is important that you select behaviors that will address the issues that have risen to the surface in our changing times, like:


Discomfort seeing our images online

Tiredness, exhaustion 

Guilt for focusing on our families over others 


Panic Attacks 






To start developing your self care routine,  you need a daily schedule that includes a variety of breaks. Due to my domestic and international commitments, my work days begin early and end late, but I try to insert a 15 minute break for each hour that I work, a two hour break for lunch that may include a yoga class, cooking or relaxing, and an hour break for a quick walk and a snack. Once you commit to a structure that works for you, insert only the behaviors that you’ll find rewarding, enjoyable or fun. Some examples of self care activities that people have shared with me over the past few weeks include:

Drinking lots of water and herbal teas

Playing musical instruments

Playing games online or with family members

Having an exercise mat nearby

Listening to music

Reading a novel

Doing puzzles


Creating a theme to follow for the day

Experiencing your emotions

Taking longer breaks

Spending time with pets

Spending time with children

Starting your day with yoga or meditation

Trying an online exercise class like ballet

Waking in the woods, on the beach, in your neighborhood

Hosting dinner on zoom with friends and family

Talking on the phone

Creating a sanctuary at home

Taking baths and showers

Reaching out to others when feeling isolated and out of control


I had some misses this week. I missed two online meetings, I was an hour late for another, and on one day I worked through one of my breaks and didn’t get to my walk. It was no surprise to me that on that night, I woke up to an ‘acting out’ dream where I threw a party in a big house full of people coughing and sneezing. I woke up in a panic, engulfed in free floating anxiety and I remembered the guidance of Dr. Patricia Coughlin, author of Maximizing Effectiveness in Dynamic Psychotherapy, “What can you do to feel more in control?”

I’m experiencing daily tiredness that momentarily lifts and then settles back down, gently arriving and receding like the fog in San Diego. It’s unsettling, this sudden shift in my life, and I’m using everything I have learned about self-care to help myself adapt to what is my new normal-working from home, online appointments and virtual teaching.

What I learned from this week is that if I feel my feelings and connect with others, my tiredness retreats for a while and I’m able to access a healthy sense of activity and joy for being. I better understand that feelings of loss today are intermingled with feelings of loss from my past. Structure helps me do the things that are necessary so I can feel more balanced and connected, it allows me to get my walks in, do some yoga, get organized and experience things I enjoy with others.

On August 13, 2010, I wrote an email to Leigh McCullough, days before I was to meet her in San Diego so I could hear her voice for the last time. I wrote, “All I can do is get out of my way, leave my ego on the shore, float downstream and be still until more is revealed.” It strikes me that those were such wise words at the time, little did I know of the complex challenges facing me as she slowly, but surely became ‘locked in’ before her death in June 2012. That period of my life wasn’t my hardest period, that was yet to come, but it was my most constructive. I learned what I was capable of becoming- myself.

As we face this pandemic together, I trust that one day, we’ll remember the lessons we’ve learned, the feelings we’ve shared, the bonds we’ve built and experience a sense of letting go and accepting what is our new normal.

In parting, I want to share the wise words of my Swedish colleague, Jenny Svebeck- sometimes it helps to remember that  “Everything is Now!”



Website ManagerAn Intimate Letter to My Community Dealing with the Pandemic by Kristin Osborn
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Therapist Affect Phobia: Reflections from Kristin Osborn from our 2 Day Virtual Conference

On Saturday, March 21st and Sunday, March 22nd with only 5 days of preparation, I hosted a 2 day virtual event: Introduction to Affect Phobia Therapy: Our Patients, Our Own and Our Work with Clients organized with the help of Dr. Alexander BeeBee and Dr. Bruce Spring of the West Coast ISTDP Consortium (WIC).

Website ManagerTherapist Affect Phobia: Reflections from Kristin Osborn from our 2 Day Virtual Conference
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