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Exeter conference day 1: resistant depression, thought suppression, self-help, & rumination from the horse's mouth

So we're past yesterday's workshops and into the first day of the conference proper.  Two and a half days now involving about 51 symposia, 5 panel debates, 8 open paper sessions, 2 poster sessions, and 17 keynote addresses.  I really like this Exeter campus with it's trees and little paths.  Easy to get lost, but lovely.  I also really like the many casual conversations - in coffee queues, at breakfast, with whoever's sitting beside you in a lecture.  Lots of interactions.  The conference attenders are almost universally friendly and easy to strike up chats with.  We all have the shared interest of psychotherapy, so it's very straightforward to hit the ground running when talking to complete strangers.  At the same time, I sometimes find these conferences quite lonely - great for social integration, not so great for social intimacy!

This morning started a bit abortively.  I'd chosen to go to a 9.00am panel debate on "Resistant depression".  I was there in good time and tumbled into a conversation with my neighbour about what the panel presenters would be likely to say.  When the forty or so of us seated there had been waiting for quarter of an hour or so after the discussion was supposed to have started, we wondered if there'd been some kind of hitch.  A phone call to one of the scheduled presenters dug out the fact that a key contributor had gone down with swine flu and the panel discussion had been cancelled.  Not great communication by BABCP.  Wherever else they had put notices, they should have had one on the meeting room door letting us know the presentation had been cancelled.  Humph.

Back to my room, where I am now, to do a bit of thinking ... and wonder a bit more what might have been said by the panel contributors if the discussion had gone ahead.  Richard Morriss had been due to talk about "Using medication to complement cognitive therapy".  It's certainly likely that some people who do not respond to psychotherapy will respond to medication (and vice-versa)  .  It is also reasonable to try a mix of both psychotherapy and medication as, particularly in more difficult cases, combination treatment may have more to offer than either psychotherapy or pharmacotherapy on their own.  Overall the decision whether to augment CBT with medication is not entirely straightforward, but in some cases is likely to be worthwhile.  Paul Gilbert was then due to speak on "Compassionate Mind Training for shame based self-attack in treatment resistant depression".  In many ways, this is the presentation I'm saddest not to have heard.  I think compassion-based interventions often currently run ahead of their research base.  I haven't come across any solid research studies on compassion/goodwill/loving-kindness interventions for clinical depression (let alone treatment-resistant depression).  However Paul published an interesting small case series in 2006, so reporting more convincing data was a real possibility today.  Damn ... it would be great to have heard.  Still Paul is giving a plenary presentation later in the conference, so there will be other opportunities to catch up with his more recent work (actually I went to the plenary and there doesn't seem any good larger trials yet).  I will also be very interested in any information on mechanism of action.  Barbara Fredrickson's excellent research on loving-kindness meditation published last year suggested that benefits might be mediated through increases in daily positive moods.  I wonder, even if Compassionate Mind Training helps with treatment-resistant depression, what mechanism(s) it acts by.  It would help to know, as it would effect how one presented the training and what one emphasised.  The third presentation was to have been by Willem Kuyken on "Mindfulness based cognitive therapy in treatment resistant depression".  Kuyken was a key author of the fascinating study published last year on MBCT treatment as an alternative to maintenance antidepressants.  A  real pity not to hear more from him!  Time to head off (through a rain storm) to a plenary with Christine Purdon on thought suppression.

Well that was wet - the walk through the rain - a bit surprising for Cornwall in mid-July.  Purdon talked on "Try to think unsexy thoughts, try to think unsexy thoughts, try to think unsexy thoughts ..... Doh!  What has 20 years of thought suppression research taught us?"  She began with a great clip of Homer Simpson trying to suppress sexual thoughts and then discussed the helpful and unhelpful strategies he tried to use.  She then went on briefly to review the current state of research on intrusive thoughts and suppression.  Like many other CBT therapists I fairly often comment to clients that attempts at thought suppression may well produce the "ironic effect" of actually producing increased frequency of the unwanted thought (Daniel Wegner's famous "white bears" effect).  Purdon argued, with justification, that real life isn't so simple and that at times suppression can work reasonably well.  It seems to be less successful when it's a whole set of events that one is trying to suppress rather than just an individual thought.  This may be part of the explanation why the detrimental effects of thought suppression are particularly obvious in Posttraumatic Stress Disorder (PTSD).  Purdon argued that  the key issue is not so much the attempts to suppress the thought, as the internal judgement one makes about having the thought in the first place.  Thus if one feels that having a particular kind of thought is deeply unacceptable and "dangerous", then one is likely to be particularly alert to any times that the thought intrudes (selective attention).  It seems that these occasional re-encounters with the deeply unwanted thought reinforce fears about loss of control, and about what having this thought means about oneself as a person (catastrophic interpretations).  It is suggested that it is this catastrophic meaning given to having the thought that is at the heart of the problem more than whether one tries to suppress the thought or not (avoidance & safety behaviours).  In the end for simple day-to-day clinical work, this different understanding may not change what I do by much.  I will still show people the sheet highlighting that it's very common for all of us to occasionally have a variety of potentially "shocking" thoughts.  I probably won't quote Wegner's White bears experiment much any more, but I will highlight that it's our catastrophic interpretation of the significance of having such thoughts that seems crucial.  As Christine Purdon recommends with intrusive thoughts, and with anxiety symptoms more broadly, it's probably often best to adopt a sort of internal "so what" shrug.  This mindful "acceptance" lets the symptoms simply go by without making a big deal about them (they're part of the human condition), and then we focus more on value-led activities and interests.

After lunch I headed over to symposium 21 described as "Helping ourselves to good mental health: the self-help perspective".  Oh dear, maybe I'm getting too critical in my old age, but this symposium seemed to be focusing on something that wasn't clearly marked "on the tin".  So we had three initial presentations that were primarily about how to write self-help books.  Ouch.  I'd hoped for an interesting look at the pluses and minuses of self-help, with evidence-based advice on what works best and how to encourage it.  I'm aware of a wealth of up to date publications on this and it's a highly relevant and topical area.  So articles this year include Van't Hof et al's Self-help and Internet-guided interventions in depression and anxiety disorders: a systematic review of meta-analyses, van Straten et al's Self-help therapy for insomnia: a meta-analysis, Riper et al's Translating effective web-based self-help for problem drinking into the real world, and MacLeod et al's Cognitive Behaviour Therapy Self-Help: Who Does it Help and What are its Drawbacks?  I slipped away at the coffee break.  A good symposium if you wanted to write a self-help book, not good if you wanted to look at self-help more broadly.

Happily the final plenary presentation I attended today was the real deal - Susan Nolen-Hoeksema from Yale on "The toxic effects of rumination".  The allocated room was too small and I could only find standing space looking in through the door - poor administration again BABCP - but still well worth going to.  Inspiring to get an overview of a top researcher's many years of work. 

For more details see the Yale Depression and Cognition Program and too her 2007 popular book "Eating, drinking, overthinking: women's destructive relationship with food, alcohol and depression".  Then talking, walking, catching up with a couple of friends and heading out for dinner in the town.


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