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The Ben Lui group (second post): how to know when to change direction on a walk or in treatment for psychological difficulties!

A couple of lines from the Bruce Springsteen song "Hungry heart" kept going through my head - "Like a river that don't know where it's flowing, I took a wrong turn and I just kept going."  Something was wrong.  I couldn't work out where I'd got to on my map.  The line of pylons shouldn't have been where they were - and certainly not where they were in relation to the stream and rough track I could see across the valley. 

I'd started walking fine in the morning.  I left Edinburgh early and before 9.00am was heading out from Dalrigh on the long walk up the valley to Ben Lui.  Two hours walking saw me at the bottom of the hill.  Then a steady tramp up and into the low lying cloud. 

Walking up into the mist on Ben Lui

Not easy.  The Munro guide had said "Once more level ground is reached in the corrie, climb north-west up steeper slopes to reach the north-east ridge of Ben Lui which forms a prominent spur called Stob Garbh.  There is a path leading up to the spur and continuing up the crest, which becomes progressively steeper and narrower.  There is no difficulty in summer, but in winter this is quite likely to become a serious climb by hillwalkers' standards."  The mist was quite thick.  I wasn't certain that I had reached the level ground the guidebook was describing.  Pretty quickly as I headed up north-west any semblance of path disappeared amongst the rocks.  I was experimenting with recording thoughts into a light little Olympus dictaphone - a much more convenient medium than notebook and pencil.  Playing this back now, I hear myself (through the sound of the wind) saying "So the path has evaporated in the mist.  Headed out north and west trying to find a ridge that I can't see.  Knowing that as I go further up it's likely to get steeper and steeper and very difficult to see where tracks might be ... working from map, working from compass, but not totally sure where I'm starting ... " and a little later "Then for a while it's all fours, quite loose clumps of rock, wet grass, try to head up on top of the ridge ... which I'm now onto.  I think it's OK.  I think this is where I should be.  So fingers crossed."  And it was fine - up the narrowing, steepening ridge and then to Ben Lui summit, still in mist.  From there I walked south-westerly down to the col and up to the top of a second Munro, Beinn a' Chleibh.  Five hours with the casting around not seeing clearly.

And as the forecast had predicted (it sometimes gets it right!), the cloud was now clearing.  My plan here was to choose between walking fairly directly back to the car, or going back by a loop further south and taking in a couple more big hills.  I was cheered by the improved visibility and decided to go for a couple more hills - Ben Oss and Beinn Dubhchraig.  From the col between Beinn a' Chleibh and Ben Lui I walked south east down the valley, tracking along the southern slope of a big ridge leading away from the summit of Ben Lui.  I'd assumed from the map that I would see where I could turn east-north-east to gain another ridge up to Ben Oss.  And this is where I made the obvious mistake.  Foolishly I hadn't worked out how long I should allow before starting to become concerned if I hadn't yet found the Ben Oss ridge.  I kept walking not realising that the ridge I was contouring along was hiding the turn I should be making.  Hence, too much later, my realization that something was wrong - that the pylons, stream and rough track I could see across the valley didn't fit anywhere on the map I was carrying (a print out from an Ordinance Survey computer programme).  I ended up walking a big loop round south of the two further Munros, getting back to the car nearly twelve hours after I'd left it.  It's the kind of mistake that long summer days are kind to, but foolish nonetheless.  It left me thinking a bunch of things.  As a walker, it really hammered home what I should have been doing - with the different sections of the walk - work out how I'll know if I go wrong or overrun.  Work it out by time and by what I'm likely to see on the ground.

And that made me think about the same issues in therapy.  How soon does one know whether treatment for a psychological difficulty is working or not?  Whether it's some form or psychotherapy, or self-help, or medication, how soon - if one isn't reaching the goals, the improvement, one wants - how soon should one be taking stock and deciding to try something else?  There's a well-established urban myth that medication treatment for depression takes several weeks to kick in.  Posternack & Zimmerman described a meta-analysis of 47 antidepressant research studies (up to the end of 2001) that measured response speed and they wrote "Drug-placebo differences were not only present but were most pronounced during the first 2 weeks of treatment and diminished in a stepwise fashion thereafter. A series of subanalyses confirmed that this early drug-placebo separation was clinically observable and represented a true drug effect. Conclusion: These results challenge the notion that a delay exists before a true antidepressant effect occurs."  More recently Tylee and Walters wrote " ... a meta-analysis of placebo controlled trials of selective serotonin reuptake inhibitors suggested that therapeutic response is greatest in the first week, with a gradual decline in the size of benefit over successive weeks of treatment.  One third of the total effect seen at six weeks was apparent in the first week. As the studies were placebo controlled trials, this improvement was unlikely to be a placebo effect."  Despite useful clarification in subsequent correspondence (see, for example, the letter by Alex Mitchell), the key point remains - if there is no noticeable improvement in the first couple of weeks on an antidepressant (used for anxiety and depression - maybe allow a bit longer for OCD), the chances of achieving a worthwhile response over the next month or two start to become fairly slim.  Having said that, most episodes of depression are self-limiting anyway - see for example Coryell, Akiskal et al and Solomon, Keller et al - so if one keeps hammering on with an ineffective medication or psychotherapy, eventually one is likely to get better anyway because of the passage of time (not because of the therapy)!

Psychotherapy too should produce some change surprisingly quickly for depression and anxiety.  The classic Crits-Christoph, Connolly, et al study "Early Improvement During Manual-Guided Cognitive and Dynamic Psychotherapies Predicts 16-Week Remission Status." reported "This study examined the extent to which improvement from baseline to weeks 2, 3, and 4 on the Beck Depression Inventory and Beck Anxiety Inventory predict week 16 clinical remission for patients with major depressive disorder, generalized anxiety disorder, and/or obsessive-compulsive or avoidant personality disorders who were receiving manual-based psychotherapies. Logistic regression and receiver-operator characteristic analyses revealed relatively accurate identification of remitters and nonremitters based on improvement from baseline to sessions 2 to 4 in both original and cross-validation samples. Predictive success did not vary as a function of diagnosis, treatment type (cognitive or dynamic), or treatment status (short-term or long-term). The clinical implications of the results are discussed."  Fairburn and colleagues have similarly shown the value of some early improvement when trying to predict longer term therapy outcome for bulimia.  I don't want to overplay this point about the importance of early improvement in predicting eventual outcome.  Clearly there are some difficulties - for example treatment of personality disorder - where one can expect more time to be needed.  And conditions like chronic depression are unlikely to remit simply with the passage of a few months.  However with many psychological disorders, if the first 3 or 4 sessions of treatment have not produced some encouraging progress, then it is usually sensible to be bringing in new treatment ingredients (changing medication or shifting approach/format in psychotherapy) or trying a different therapist. 

This all links with the crucial importance of combating demoralisation and beginning to feel hope of recovery as one begins some form of therapy.  Does this therapy make sense to me?  Does it sound like it could help me?  Does this therapist seem good?  Do they listen to me and seem to understand what I've been going through?  These findings on the importance of some early improvement in predicting longer term success mean that it makes very good sense to track how symptoms change week by week - see, for example, the "Attitudes to therapy scale" and the "Progress charts" listed at the end of the handouts page "Introduction & monitoring".     


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