Warwick BABCP conference: 1st morning - trauma memories & a master presentation on four decades of outcome research (2nd post)
Last updated on 6th August 2015
Yesterday I blogged about the pre-conference workshop I attended on "Anger dysregulation". Today was the first full day of the conference proper. Breakfast illustrated the kind of helpful, fun conversation that can emerge at this kind of event. I talked to Fiona McFarlene & Tara Murphy who were going on to run a skills class on "Exposure and response prevention: adapting skills you already have to the treatment of tics". They spoke about this interesting addition to the habit reversal techniques I already use for this kind of disorder ... a sort of interoceptive ERP exercise using the urge to perform the tic behaviour as the intrusive experience and the tic movement as the compulsive response one prevents. Good stuff.
Then on to the first symposium of the day (one of 12 parallel choices - the 141 page "Abstracts book" contains information on all keynotes, symposia & posters). The first symposium was actually a panel debate on "Current approaches for addressing traumatic memories in distress-related disorders: commonalities and differences, indications and contraindications". This is a tricky area. We had Jonathan Wheatley talking about working with intrusive memories in depression (a good reminder), Florian Ruths discussing imagery rescripting in schema-focused work, Thorsten Barnhofer speaking about trauma memories and mindfulness training, and Jennifer Wild reminding us of Ehlers & Clark style PTSD interventions used in social anxiety. Then Gary Brown acted as 'discussant'. Mm ... what did I learn? Not a lot. I guess I know a good deal about this territory and we're still at the Chairman Mao stage of "Let a 100 flowers bloom, let a 100 schools of thought contend". I was tempted to jump in to argue that there might be a real parallel here with behavioural activation in depression. So there's a ton of work highlighting that Edna Foa's "prolonged exposure therapy" stacks up very well when compared with more involved trauma processing techniques. There's also good work showing that it's comparatively easy to train effective therapists in prolonged exposure interventions (as it is with behavioural activation). So maybe there's a good argument for KISS ... see the blog post "Working with traumatic memories: KISS (keep it simple, stupid) and the virtues of straightforward prolonged exposure" with its lovely Leonardo da Vinci quote "Simplicity is the ultimate sophistication". I also wondered ... again as with depression, see "New research suggests CBT depression treatment is more effective if we focus on strengths rather than weaknesses" ... whether paying more attention to clients' pre-existing strengths might give helpful hints about what kind of trauma-processing work to use. For example a client with strengths in self-compassion might do particularly well with a self-soothing rescripting intervention, while a client with strengths in mastery & courage might prefer (and respond better to) straight-down-the-line prolonged exposure. Anyway, there were some take-home messages for me ... remember that memory work might be useful especially for depressed clients with more frequent memory intrusions, and that intrusive memories & rumination seem sometimes to mutually reinforce one another. Remember too how Arnoud Arntz may come in to "protect" a client in memory-processing before the hot spot is reached (this can be a kind initial approach to use for example when reprocessing sexual abuse/assault ... although one might move to working with hot spots if outcomes aren't being adequately achieved). I was interested as well to be reminded of the research on brain changes following abuse (e.g. less brain volume covering the genital area after sexual abuse, and less the face area after emotional abuse ... see "Decreased cortical representation of genital somatosensory field after childhood sexual abuse"), linking to the notion that, for example, mindful tracking through the body can be acting partly by "reclaiming neurological deserts"! Overall this imagery/memory reprocessing work is such interesting territory but I think it can easily degenerate (at our current stage of research) into a confusion of voices ... but it was of some value for me to "listen in"!
Then on to a master presentation ... Pim Cuijpers on "Four decades of outcome research on psychotherapies for adult depression: what next?" Wonderful. Worth at least half the overall conference fee for me just to attend this plenary lecture (and I'm pretty familiar with his publications). As invigorating as a cold shower, I had a slight (probably over-patronising) feel of "pas devant les enfants" for new therapists here. Pim covered 1.) what have we learned about CBT for adult depression, 2.) the need (or not) for new treatments, 3.) new directions, and 4) conclusions. With 1.) he looked at the effects, comparison with other psychotherapies, comparisons with antidepressants, characteristics of patients, characteristics of therapies, other outcomes, and causes of overestimation of the effects. He talked about his team's constantly updated database of RCT's on therapies for depression (with its over 60 published meta-analyses) and its open availability for other researchers to use. He described how he tries to convert effect sizes into NNT's to make them more useful and commented (with no NNT!) that they estimated an effect size of 0.24 is the threshold for clinical relevance. He showed an interesting slide illustrating the blossoming of depression research outside the US in recent years. He showed overall effect sizes & NNT's for depression trials involving CBT, behavioural activation, interpersonal psychotherapy, problem-solving therapy, supportive therapy, psychodynamic therapy, MBCT, and other interventions. IPT came out marginally ahead and supportive therapy marginally behind in one of their major reviews, but subsequent work throws doubt on the clinical relevance of these conclusions. Pim suggested that, because of the volume of research, it's a safe choice to start by using CBT, IPT or BA for depression treatment when they're available.
He then talked about pharmacotherapy and highlighted more strongly than I had taken on board before the value of using combinations of pharmacotherapy & psychotherapy for depression. I had a query in the back of my mind here about the possible detrimental effects at follow-up of adding pharmacotherapy unnecessarily because the client might feel that it was the medication that did the work and that they are then rather powerless/helpless without it ... important probably to boost/support the client's sense of their contribution to any improvements they achieve. Other points of interest included the somewhat poor quality evidence underpinning the conclusion that pharmacotherapy is significantly more effective than psychotherapy for dysthymia (although this is what the evidence so far suggests). Pim underlined the value of CBT at follow-up. I hadn't realised before that even at one year follow up after CBT with (almost) no maintenance, outcomes are somewhat better than for clients on continued maintenance antidepressants. Gosh. I would like a head-to-head between the relapse prevention effects of targeted CBT and MBCT, or at least to remind myself of the research status of this question. (Self note here: Khoury et al's 2013 paper suggests little difference between CBT & MBCT - see "Mindfulness-based therapy: a comprehensive meta-analysis"). It's clear, we were reminded, that psychotherapy holds up well across virtually all studied populations (e.g. different ages, educations, comorbid physical conditions, etc) ... although watch out for comorbid alcohol problems. Pim emphasised the value and good sense of group and guided self-help approaches. He talked about treatment intensity and again made a couple of points that I appreciated being reminded of. One is the rather small association between number of sessions and treatment effect (illustrating the value of titrating session number to client response rather than pre-deciding how many treatment sessions to provide). The other ... and this is such an interesting point ... is the strong positive association between number of sessions per week and outcome - see "How much psychotherapy is needed to treat depression? A metaregression analysis". In fact two instead of one session per week seems to increase effect size by 0.45 (with total session number held constant). Damn ... this would be hard to manage in my own private practice, but it's important. As the metaregression paper notes "More research is needed to establish the robustness of this finding. Based on these findings, it may be advisable to concentrate psychotherapy sessions within a brief time frame." Intriguing ... worth bearing in mind as a real possibility ... and definitely a research area to try to keep track of.
Then Pim poured a very large metaphorical bucket of water over us with his comments about the decreasing effect size of CBT as one looks coolly at issues like allegiance effects, the inadequacy of wait list control groups, poor quality trials, and other sources of bias. We're looking at reduction here from an effect size of 0.71 for all studies (and a NNT of 3) to an effect size of only 0.31 adjusting for publication bias (with a NNT of 6). Bloody hell. Bring on the pharmacotherapy augmentation and doubling the number of sessions per week! And, of course, there are powerful therapist effects to be considered as well - see "Warwick BABCP conference: 3rd day - even more evidence that therapists themselves are central to improving outcome" - (but Pim didn't venture into this territory). He kindly reminded us that these mental health effect sizes are fairly similar to outcomes in the general medical field. Yes I know this, but I still stagger away a bit demoralized when I'm reminded so forcefully of how much more progress we need to make in tackling depression better (and of how slow & ineffective our efforts have been in achieving this). Pim went on to state that ...without convincing new reasons ... he felt we did not need any new acute treatment depression therapies (the Dodo bird wins here it seems), and that it's a waste of money & resources funding more head-to-head comparison trials of differing therapies, differing delivery formats, and differing target populations (we pretty much know the answers to these questions already). What he felt we do need is more work on depression prevention, on improving treatments for chronic, treatment-resistant depression, more focus on relapse prevention, more personalisation of who benefits from which treatment, and also better understanding of how people recover (with or without treatment). He also feels we should scale up and simplify treatments by greater use of lay health counsellors, group therapies, and guided self-help approaches ... behavioural activation interventions are front runners for this scale up & simplify injunction, see the post on tomorrow's presentations "Warwick BABCP conference: 2nd day - behavioural activation, Kyrios OCD, 'mind the gap', & DeRubeis on personalization (4th post)". Yup. I zipped up to the front afterwards to thank him. A very good presentation.
And for the next post in this sequence, see "Warwick BABCP conference: 1st afternoon - treating adolescent anxiety & depression, and depressive rumination (3rd post)".