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Exeter pre-conference workshop: Ed Watkins on CBT treatment for anxious & depressive rumination

Exeter.  I really like the way that the British Association for Behavioural and Cognitive Psychotherapies (BABCP) conferences rotate around a whole series of UK university towns.  This is the 37th BABCP Annual Conference, and I guess I've been to a dozen or more of them over the years.  They tend to follow a similar pattern - beginning with a choice of optional one day workshops, followed by two and a half days or so of conference proper.  There are about 20 one day workshops to choose from this year, and I've plumped for Ed Watkins's "CBT to treat anxious and depressive rumination" (click on the workshop title for a fuller description).

The workshops run from 9.30am to 5.00pm.  At a very rough guess, we have 50 or so participants in our group.  The room is too cramped and, as is routinely the case with BABCP pre-conference "workshops", it's a bit more of a lecture (with a fair amount of chance for discussion and a smallish quantity of experiential work) than my idea of a real hands-on style workshop.  Still the most recent Cochrane review on "Continuing education meetings and workshops: effects on professional practice and health care outcomes" is encouraging about the helpfulness of these mixed didactic and interactive educational formats - although the review cautions against their value in changing complex behaviours.  The review is also less polite about more purely didactic forms of education, and the rest of the conference is sadly very lecture based.

Despite the room and the heat, Ed Watkins's workshop certainly held my interest.  He focused on rumination as a key pathological process in depression - and emphasised too that there are strong overlaps between depressive rumination and anxious worrying.  At the end he gave details of a small, as yet unpublished, randomized controlled trial using his recently developed Rumination Focused Cognitive Behavioural Therapy (RFCBT) with a hard to treat group of people suffering from persistent depressive symptoms (BDI's in the upper 20's) despite being on antidepressants.  Twelve sessions of RFCBT produced impressive results and compared very well with previous outcomes reported for this patient population using more standard CBT.

It's hard to do a concentrated full day workshop justice in just a few short paragraphs.  Key points I take away are how commonly people with major depression are left with significant residual symptoms despite treatment (possibly about a third of depression sufferers) - which reduces their quality of life and considerably increases their likelihood of subsequent relapse.  This is the population RFCBT currently aims to help.  RFCBT views avoidance and rumination as normal - sometimes adaptive - behaviours, which play a major role in maintenance of depression.  A contextual, functional approach is emphasised, overlapping considerably with the more widely researched Behavioural Activation.  RFCBT also includes an explicit emphasis on trying to shift cognitive processing style from an abstract, general, evaluative, "why" focus to a more concrete, specific, "how" focus.

I already often use a Behavioural Activation approach for depression treatment.  I like the way that Ed's careful exploration of a client's recent episode of rumination (as I already do with panic episodes) produces a very personalised, functional understanding and allows selection of good ways forward in dealing with their rumination.  Again it complements BA's TRAP to TRAC model.  It also links very nicely with both Implementation Intentions and with Reappraisal.  I already spend a fair amount of time "warning" depression sufferers (and worriers) about the unhelpfulness of simply batting round and round in their heads ruminating.  I typically say something like "Simply ruminating or worrying about your problems is like a bird trapped in a room.  It batters about and usually just feels worse and worse.  It's likely to be much better to either problem solve with a pen & paper or speaking with a friend, or redirect your attention to some other activity."  What Ed Watkins' work adds for me is how careful functional analysis allows identification of the triggering situations (environmental or internal) and personal function of someone's rumination.  This links beautifully with implementation intentions' methodical setting up (and practice) of action plans to deal with future roadblocks - "If X occurs, then I will do Y".  

Ed also talked about and demonstrated ways of helping clients change their thinking style from over-general rumination/worry to more concrete, in the present, styles of attention.  Specific examples include applied relaxation, flow and compassion/goodwill.  I was a little doubting at this section of the workshop.  One reason for the doubt was a query about the prolonged time and effort needed to genuinely get much better at shifting attentional style.  I may be wrong here, but after nearly forty years of mindful meditation practice, I'm not convinced that a few in-session therapy chats are going to significantly change a person's ability to "come into the present" more often.  Maybe though, just a little is enough to free somebody up and help them shift out of rumination more readily.  There is more on this blog about teaching applied relaxation.  The classic 1993 Carlson review of progressive muscular relaxation found that it probably needed about 12 hours of training (and the associated home practice) to get really competent at this technique.  For further ideas on flow, I recommend chapter 7 on "Living in the present" in Sonja Lyubomirsky's fine book "The how of happiness".  In fact I'd recommend the whole book

For compassion/goodwill, there are a series of blog posts I've written.  Ed showed a video of his approach to helping people shift to a more concrete compassionate way of interacting.  It followed a very similar sequence to the one I've described in a series of posted meditation practices.  I liked the way Ed took a client through the challenges of allowing a sense of compassion in progressively more difficult situations while monitoring how easily they were managing to make these changes - and, when necessary, looking at how to cope with blocks to this process.  I think I can learn from this - probably by initially giving clients the relevant meditation practices, but then by checking how they're managing and problem solving blocks in this more RFCBT way where appropriate.  Certainly Paul Gilbert's talk (on the final day of the conference) about how difficult - and anxiety provoking - some people find developing a sense of compassion for themselves suggests that this in-session problem solving approach might be useful with this sort of difficulty.

Ed also talked about value-directed action and enhancing wellbeing.  As a final query I wonder if some of the benefits from teaching clients to shift into more concrete, specific thinking styles may in fact be produced by promotion of wellbeing rather than simply by interrupting rumination cycles.  Barbara Fredrickson & colleagues' study on loving-kindness meditation certainly suggested that the way this practice boosted positive emotions seemed a key mechanism producing benefit.  Autonomous value-directed action is a core component of wellbeing enhancement and we know that increases in wellbeing impact depression

Overall a helpful, interesting workshop.  Fascinating both to try out some of the ideas ... and to see how well supported this approach will be as further research emerges.



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