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Exeter conference day 2: mindfulness & health anxiety, body dysmorphic disorder, therapeutic alliance, and politics

Second day of the full conference.  Again good conversation at breakfast ... great.  Then off along small tracks through the university grounds to end up at a symposium on research using Mindfulness-Based Cognitive Therapy (MBCT) to help people suffering from severe Health Anxiety Disorder.  Four papers were presented.  Although the trial intends to recruit 60 participants in total, these papers were just on early completers.  I was interested that the researchers used a variety of assessment measures including the Five Facet Mindfulness Questionnaire (FFMQ), Neff's Self-Compassion Scale (SCS), the Short Health Anxiety Inventory (SHAI), and the Beck Anxiety Inventory (BAI).  In their initial group of participants over the eight weeks of the MBCT training, FFMQ scores increased (I think) from about 115 to 126, SCS scores from about 75 to 87, while SHAI scores decreased from about 30 to 24, and BAI from about 17 to 14.  I was a bit surprised by the small reduction in the BAI.  In a recent relaxation for anxiety disorders meta-analysis, the BAI was mentioned as the anxiety measure that seemed easiest to shift with these approaches.  I've tended to find BAI scores drop by about 50% over the course of the eight week Autogenic Training courses that I run.  It may well be that anxiety is harder to reduce in a group of Health Anxiety sufferers, but it does rather support my sense that MBCT may not be such a great intervention for anxiety symptoms.  So for example, in a pilot trial of MBCT for Generalized Anxiety Disorder reported last year, the authors concluded "Overall, the findings suggest MBCT is definitely worthy of further investigation as a treatment option for GAD, but falls well short of outcomes achieved by past research."  It makes me a bit more determined to include some emphasis on relaxation as well as mindfulness in the Lifeskills & Stress Management course I'm designing for this autumn.  Nice to hear about their work though, and to catch a word with Mark Williams in the coffee break.  After coffee there were third and fourth papers presented on this study's interim results.  I tend to be quite a fan of quantitative research, so I was struck by how much interesting information emerged from a small qualitative study on these early completers experience of the MBCT course.  Various themes were noted including the value of sharing experiences with other Health Anxiety sufferers in the group format, the difficulty experienced by participants with the request to meditate for relatively long periods of time (maybe the Autogenic 10 to 15 minute exercises are more realistic), and the wish for more organized follow-up.  Overall an interesting snapshot of work in progress.

Next I headed up to a plenary with Sabine Wilhelm talking on "Beauty and the beast: the nature and treatment of body dysmorphic disorder".  Wilhelm works at the Massachusetts General Hospital Body Dysmorphic Disorder Clinic & Research Unit and has written a good self-help book on BDD called "Feeling good about the way you look".  The lecture was excellent with a whole series of useful take-home points including how disabling & distressing this condition is, the high doses/longer time to response needed for antidepressants (SSRI - a quote dose for example of citalopram that I scribbled down as 66 +/- 33mg.  I'd want to check that, it seems a very high dose to me), and the encouraging results obtained in a CBT trial using relatively inexperienced therapists providing 20 weekly and 2 fortnightly sessions to achieve a well-maintained approximately 50% reduction in BDD-YBOCS for treatment completers.

After a shared lunch with another colleague, we went on to the Panel Discussion on "Having you cake and eating it: integrating therapist and therapy effects to maximise clinical outcomes".  There were various heavyweights, including David Clark, putting their points of view.  Terry Wilson from Rutgers in the USA came out with a somewhat combative set of claims that CBT is what matters and therapist effects are minimal compared with the importance of therapy method chosen.  David Clark gave a more balanced talk suggesting that both therapy and therapist effects are important with considerable variation across different situations.  As usual, he produced nice slides impressively illustrating his argument that, for many anxiety disorders, it is well practised CBT that is more important than therapist contribution.  Michael Barkham from Sheffield also came up with some interesting points highlighting variability of therapist outcomes in research involving, I think, nearly 300 primary care counsellors.  The top few percent of therapists achieved considerably higher response rates than the general mass of more 'average' counsellors in this study.  Possibly even more alerting, the bottom few percent of therapists were achieving considerably lower response rates than the 'average' counsellors.  The difference between the top and bottom groups was large indeed.  Barkham suggested that it might make very good sense to identify particularly effective therapists and then study them to see what we can learn from their practice.

Then again a plenary, this time with Lord Layard on "Making psychological therapies a national priority".  I have his book "Happiness: lessons from a new science".  It's good ... and so was his talk giving background on the Increasing Access to Psychological Therapies initiative and introducing initial work on extending these ideas into child and adolescent services. He commented too on the general public outlook for work in mental health and discussed as well the importance of emotional intelligence education for children.  By the end of this, I was feeling rather "lectured out".  Time to have a cup of tea, go for a walk exploring the university grounds more, and make a couple of family phone calls.


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