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Leeds BABCP conference: compassion focused therapy & CBT, John Vlaeyen & treating chronic pain problems (8th post)

In June I wrote a series of five posts reporting on a pre-conference workshop (about treating chronic fatigue) and the first day of the British Association for Behavioural & Cognitive Psychotherapies (BABCP) main annual conference, held this year in Leeds.  Then last month I wrote a further couple of posts.  Now here is the eighth and final report in the sequence:

The last day of the BABCP main annual conference in Leeds was the usual mix of presentations & conversations.  I had breakfast with a couple of delightful researchers earnestly discussing the technicalities of a proposed new questionnaire about genital dissatisfaction.  Mm ... not a very appetising topic over the tea & toast. 

First up, I headed over to a two hour skills class given by Mary Welford entitled "How to integrate compassion focussed therapy with familiar CBT approaches".  The abstract read "CBT has proved to be of great benefit for a range of individuals.  If such work produces a sustained improvement in an individual's wellbeing it can be viewed as the most compassionate approach to adopt and should be recommended.  However, what happens when your client reports they can see the logic but they do not feel any different; they know they are not to blame but they still feel at fault; they know there may be no danger but they still feel as though something terrible will happen, despite all of your and their best efforts.  In such cases should we do more of the same or try something different?  Compassion Focused Therapy (CFT) was developed by Paul Gilbert as a way of addressing shame and self-criticism.  The therapy aims to 'tone up' feelings of contentment, safeness and soothing in order to help regulate the drive and threat systems of the brain.  This helps the individual bridge the gap between knowing something and feeling it.  It is a standalone therapy but aspects of the approach can be 'sprinkled in' to other forms of therapy to 'warm it up' or allow cognitive work to 'sink in'."  

Mary highlighted the learning objectives of the skills class as * Delegates will be briefly reminded of, or introduced to, Compassion Focused Therapy (CFT) and Compassionate Mind Training (CMT).  * A rationale will be given for why CFT may be a useful framework to think about blocks in the practice of CBT.  * Literature, microskills and techniques will be presented that can be woven in to CBT practice in order to negotiate or overcome roadblocks.  * Finally the application of CFT into the lives of therapists will be discussed as a way to help us all feel less shame and less self-critical and find a better place to listen to, learn from and assist those whom we see in practice.  It was good stuff and Mary was a great person to take us through this territory.  She's a very experienced CBT therapist, who has been heavily influenced & inspired by the CFT approach, and is currently chair of the Compassionate Mind Foundation ... their website is a fine source of all kinds of handouts & other useful resources.  The whole issue of introducing compassion-related ideas into therapy is very topical.  Paul Gilbert and Kristin Neff/Chris Germer represent somewhat different approaches in this field.  See this website's "Good knowledge" page on "Compassion & criticism" for many more relevant resources.  It all ties in with the simple, basic heart of therapy for me ... caring for another person in distress ... allowing our hearts to soften.  And this basic heart of therapy, this kindness was one of the key aspects of Mary's talk that I was most touched by.  At its best I believe that compassion-focused approaches help therapists express a deep kindness in ways that can be particularly therapeutic.  It's a blessing. 

And after the morning coffee break, I went on to a plenary presentation with Professor John Vlaeyen entitled "Chronic pain: A learning theory perspective".  OK, let me declare myself ... I think John Vlaeyen is a bit a of a "great man".  Earlier in my career I did a lot of work with people suffering from chronic pain.  Even those many years ago, I was fascinated and encouraged by Vlaeyen's therapeutic models, interventions and results.  Solid, caring, courageous, thoughtful and potentially very helpful work.  Inspiring actually to see how these ideas and approaches can help people's lives so much.  He's a professor at both Leuven and Maastricht Universities.  His Leuven webpage ends "Johan Vlaeyen is married to Nicole Note, and has two daughters Yana and Jolinde.  In his free time, he enjoys playing the viola da gamba (http://en.wikipedia.org/wiki/Viol ) and takes care of a flock of 20 Mergelland sheep (http://www.mergellandschaap.nl/)."  I like it ... and of course, I like it much more because this is important therapeutic territory.  The Leuven webpage also comments "The main interest of Johan W.S. Vlaeyen is the understanding of cognitive and behavioral mechanisms of chronic disability due to somatic complaints and pain in particular, and the development and evaluation of customized cognitive-behavioral management strategies for individuals suffering chronic pain.  His experimental work has highlighted the role of the threat value of pain in the engagement of defensive responses such as increased physiological arousal, hypervigilance and escape/avoidance behaviors. He and his team currently are examining the role of fear learning, and the pathways to the development of pain-related fear including. These include fear learning through direct experience, contextual fear learning when pain is unpredictable, observational fear learning, and learning through verbal instructions.  Johan Vlaeyen and his team also have developed exposure-based treatments for fear-reduction and they have utilized randomized controlled trials as well as replicated single-case experimental designs to evaluate the effects of behavioral interventions for patients with chronic pain." 

And having been aware of his work for so long, it was lovely to hear him speak.  Titbits of clinical insight garnished his talk ... for example, that initial client willingness and expectancy don't seem strongly related to outcome.  He tends to say something like "Just give this a try."  Expectancy often changes/improves over the course of the treatment itself.  He also commented that he would particularly tend to select patients for this therapeutic approach who had high fear-of-pain scores without obvious reasons not to engage in this kind of exposure/desensitisation based approach.  Chronic, disabling, non-specific low back pain is a problem he routinely works with ... as is complex regional pain syndrome.  He said that "psycho-education", providing a coherent, believable, alternative viewpoint to explain the persistence of the problem, tends to decrease fear of pain in itself.  Then exposure treatment leads to a further reduction in fear (would couching the exposure as a behavioural experiment improve outcomes as it seems to for panic disorder, I wonder).  Vlaeyen also pointed out (as with behavioural activation preceding improvement in mood often with persistent depression, or increased activity preceding return of energy in chronic fatigue) that with chronic pain, one may well find that reduction in disability precedes reduction in pain.  "Fake it till you make it" in some senses.  He mentioned as well that he now tends to assess fear of pain (or maybe more accurately fear of movement) by looking at responses to activity pictures more than answers to written questionnaires.  If you want to follow all this up further, a great resource is Vlaeyen's multi-authored 2012 book "Pain-related fear: Exposure-based treatment for chronic pain"

Then came the last lunch break of this interesting four days I've been spending in Leeds.  I had intended to stay on for some of the final afternoon sessions, but the news came through that there had been a landslide on the train line back to Edinburgh and travel was in some chaos.  I decided to leave a little early to try to get back to Edinburgh by night time.  It turned out to be a long stop-start journey, but I made it.  A good conference.  I look forward to next year's.

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