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Guildford BABCP conference: Rolls Royce therapy and Anke Ehlers on PTSD (third post)

I wrote yesterday about one of the first symposia of this major annual meeting - "Guildford BABCP conference ... cognitive factors that maintain GAD and worry (second post)"After the symposium, we then had to choose between four plenary lectures.  I opted for Anke Ehlers speaking on "Cognitive therapy for PTSD: an update".  Back at the much briefer BABCP spring conference in April, Lars-Goran Ost gave quite a shocking presentation - "Progress in CBT: lessons from empirical reviews" - where he stated that careful systematic review of all 409 relevant CBT research studies showed that for anxiety disorders " ... the within-group effect sizes do not, with the exception of specific phobias, show an improvement across four decades of research."  I wrote at the time "Great that we're providing real, significant benefit for people suffering from anxiety disorders.  Great that the effects transfer so very well to routine clinical settings and hold up so well at follow-up.  What about the lack of progress in making CBT treatments more effective though?  Is this true?  Are we still only as helpful as we were thirty or forty years ago?  It reminds me of decades of research on antidepressants.  Millions of pounds/dollars have been spent on research by pharmaceutical companies with minimal improvements in antidepressant effectiveness.  And why wasn't the audience in uproar?  This is important territory.  We moved on, but when it came to the teabreak I scampered after Ost and caught him on the stairs.  I asked something like "So do you think we're wasting our time coming to conferences like this?  It sounds like we should just learn basic CBT approaches for anxiety disorders and then simply keep using them without expecting that anything useful will emerge from all the beavering away by researchers trying to improve the results we can obtain."  And his reply?  Pretty much that an awful lot of the new interventions (e.g. so-called third wave approaches) aren't - so far - living up to the claims of their advocates.  See, for example, Ost's meta-analysis "Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis".  See too his paper "Cognitive behavior therapy for anxiety disorders: 40 years of progress." which covers much of the material in this talk.  Dear Professor Ost seemed to me a little like a large party-pooping Scandinavian troll who was being ignored by the happy UK audience in the hope that his message would simply go away.  Ost went on to say to me, over a cup of tea, that many experienced therapists - in his opinion - get sloppy as they age.  They take on shiny new developments that are not adequately tried & tested, and may start to cut corners with the more solidly based bread & butter approaches.  His systematic review had however found that "If the single studies that gave the highest ES (effect sizes) each decade were compared, all anxiety disorders besides panic disorder and obsessive-compulsive disorder showed a positive development." Maybe we can do better by carefully looking at who is reporting the very best results in the best high quality research studies and only altering our interventions to take on board these more Rolls Royce developments.  We probably would do well also to rigorously review our personal clinical practice - asking ourselves if we're really adequately making sure we focus on what is evidence-based and taking good care not to get seduced by every Johnny-come-lately new idea.  A good bucket of cold water to wake up my critical thinking.  Thank you Professor Ost."

I think Ost made some very important points.  It's easy to come away from these big conferences all fired up about " ... shiny new developments that are not adequately tried & tested".  As Ost highlighted though, we have a better chance of becoming more effective " ... by carefully looking at who is reporting the very best results in the best high quality research studies and only altering our interventions to take on board these more Rolls Royce developments."  Here at this plenary presentation today is a classic example.  This is Rolls Royce and it's a privilege to hear Anke speak about her hugely impressive work.  The presentation's abstract reads: "Ehlers and Clark (2000) proposed a cognitive model of posttraumatic stress disorder (PTSD).  This model suggests that chronic PTSD develops if trauma survivors process the traumatic event in a way that poses a serious current threat.  The perceived threat has two sources: first, people with chronic PTSD show excessively negative appraisals of the trauma and / or its sequelae.  Second, the nature of the trauma memory leads to easy, cue-driven trauma memories that lack the awareness of the self in the past.  Furthermore, the patients' appraisals motivate a series of dysfunctional behaviours and cognitive strategies that are intended to reduce the sense of current threat, but maintain the disorder.  A series of prospective longitudinal studies of trauma survivors and laboratory experiments supported the role of the maintaining factors suggested in the model.  Prospective studies also supported the specificity of the proposed factors for PTSD versus depression.  Ehlers and Clark's model has led to the development of Cognitive Therapy for PTSD (Ehlers & Clark, 2000).  Six randomised controlled trials showed that the treatment is highly acceptable, and more effective than wait list, self-help or an equally credible psychological treatment.  Comparable treatment effect sizes were achieved by trained clinicians in a community setting and a routine NHS clinic.  Further studies showed that the treatment is also effective when given as a 1-week intensive treatment, and that is effective in very chronic PTSD following multiple trauma and terrorist violence."

And here are some of the notes scribbled in the margins of my abstracts booklet during the talk - "Most people who experience 'trauma' recover; so what blocks recovery and leads to PTSD?"  The flow charts downloadable from the "PTSD assessment, images, memories & information" page of this website illustrate the key components that Ehlers & Clark have proposed produce this recovery block.  As Anke highlighted, to reduce the central persisting sense of threat (and other associated powerful dysfunctional emotions) we need to "give up" avoidance strategies intended to control the threat/symptoms, "identify & modify" negative assessments of trauma/subsequent events, "discriminate" the matching triggers, and "elaborate" the trauma memory.  She mentioned the very impressive effect sizes they have been achieving through their treatment - 2.4 to 2.5 (remember anything above 0.8 is typically considered "large").  She commented that changes in the three mediators (negative assessments, trauma memories, avoidance strategies) have been shown to precede - much more than follow - symptomatic improvement.  It seems that the negative assessments are the most important target for treatment.  Apparently warning signs that suggest one might get a poorer outcome include long term unemployment, never having been married, treatment need for multiple traumas, past suicide attempts, history of substance abuse and length of time since the trauma.  In a question, I mentioned Marylene Cloitre's work with complex PTSD and Anke agreed that preparatory training in affect & interpersonal regulation might well be useful for these potentially more challenging populations.  Anke said that dissociation, comorbidity (e.g. depression, agoraphobia), chronic pain and personality disorder didn't seem to interfere with outcome.  Psychological treatment tends to achieve better outcomes than drug treatment, but medication also doesn't seem to interfere with outcome.  She also reported that "experienced therapists" (those who have treated more than a dozen clients using her model) didn't seem to get better outcomes than therapists who are less experienced with the model.  However there are a couple of big "buts" here - one is that "experienced therapists" had fewer dropouts and I suspect this is exactly where one may be most likely to observe effects of increased experience (and improved working alliance).  Secondly it's appropriate to put the whole notion of Anke's "less experienced therapists" into perspective.  These are likely to be highly competent health professionals who, although they haven't used this PTSD model much before, are likely to be familiar with the types of intervention being used and - and it's a big "and" - they are likely to be have had intensive pre-research trial training and ongoing highly expert & intense supervision.  

In this brief one hour bird's eye overview of her research on PTSD, Anke talked particularly about treating trauma memories.  She commented that identifying & modifying appraisals (probably the most important intervention) and tackling avoidance are approaches that cognitive-behavioural practitioners are familiar with from their work with many other non-PTSD disorders.  Treatment of trauma memories however is more idiosyncratic to this particular understanding of PTSD.  She included in this area, intrusive memories, dreams, dissociative reactions and emotional & physiological reactions (quite possibly these latter might have no conscious link to the trauma).  She felt key questions are "Why are these trauma memories so easily triggered?" and "Why is there so little awareness that they are memories - why the sense of 'nowness'?"  She said that identifying the "triggers" to these memory intrusions/reactions might well take a good deal of detective work with the client.  The triggers often have a sensory similarity to experiences that occurred during the trauma.  There would then probably need to be work discriminating between 'then' and 'now' - noting differences and varying context.  Surprisingly she had found that clients' most intrusive memory fragments might well not actually appear in their trauma narratives (in one series, this occurred for 23% of clients).  The autobiographical memory for the worst moments of the trauma tends to be disjointed from other autobiographical information.  It isn't sufficiently 'elaborated' and the moments remain threatening because their meaning isn't updated.  Anke talked about the poor inhibition of unintentional trauma memories and the way they tended to be retrieved without context.  She highlighted the importance of updating the trauma memories.  This is likely to involve identifying the worst moments of the trauma, identifying information that updates the impressions/predictions made at the time of the trauma (what do we know now that we didn't know then?), and incorporating the updated information.

Great stuff.  A privilege to hear about this major research 'journey'.  If you work in this field and can get to one of Anke's workshops, go to it!  She's not going to be around for ever.  And tomorrow I'll write about what for me was the most shocking and helpful presentation of the whole conference - "What shall we do about the fact that there are supershrinks and pseudoshrinks?" 

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