Last updated on 27th April 2010
Friday was the "conference" day. A real old fruit salad of presentations. Nearly always I find it hard to stay awake and focused during this kind of "educational event". It does however allow a lot of speakers to throw a lot of information at the audience! The 2007 Marinopoulos et al review on the "Effectiveness of Continuing Medical Education" commented that " ... live media was more effective than print, multimedia was more effective than single media interventions, and multiple exposures were more effective than a single exposure." So probably something useful will stick and affect my practice (although I guess that's largely up to me). Overall the authors concluded that "Despite the low quality of the evidence, CME appears to be effective at the acquisition and retention of knowledge, attitudes, skills, behaviors and clinical outcomes. More research is needed to determine with any degree of certainty which types of media, techniques, and exposure volumes as well as what internal and external audience characteristics are associated with improvements in outcomes."
The day began with Warren Mansell introducing the first keynote presentation - Deborah Lee talking about "Compassionate mind in CBT: bridging theory and therapy". It's so interesting how some types of lecture work for some people and different kinds for others. Deborah shared her evolving clinical experience and changing views on the value of a compassionate mind approach. It seemed personal and made very little reference to any research data. I find this hard. There are so many interesting, experienced, and contrasting points of view about what constitutes helpful therapy - I just don't have the time to follow up these anecdotal experiences. The key quality that attracted me to CBT many years ago was its foundation on good research data, and its ability to keep questioning itself and evolving through ongoing hard-nosed clinical trials. Paul Gilbert also gave a general talk about the "Compassionate mind approach" at the end of the conference. This latter talk gave much more detail of supportive research. I would much preferred to have had Paul's talk first - underlining the research basis for taking this approach seriously - before moving on to Deborah's more clinically-orientated sharing of her experience.
Next up were three talks in a Compassionate mind symposium. Willem Kuyken spoke on "Compassion in mindfulness-based cognitive therapy: therapist embodiment and client change" - for me this was the highlight of the conference and I'll devote the whole of tomorrow's blog post to it. Kenneth Goss gave a talk entitled "Compassion focused therapy for eating disorders" - a report of introducing a group compassionate mind programme for diverse eating disorder sufferers. Results looked encouraging although they were based on reviewing clinic outcome data and not on clinical trial. After coffee Anke Karl spoke on "The role of self-compassion for recovery from trauma". She reported on, I think, four studies. She commented "PTSD is the outcome of unsuccessful trauma processing." Interesting to note that recent research suggests that depression and anxiety are more common psychiatric sequelae of trauma than PTSD. My notes are a bit sketchy here, but I think in the first and second studies Anke and colleagues had looked at a variety of factors - for example social behaviour, approach/avoidance, and attachment security - that might be associated with the development or prevention of PTSD post trauma. It had been found that higher levels of self-compassion were associated with lower levels of PTSD. This seemed, I think, to have possibly been mediated through reduced levels of rumination and avoidance (especially social avoidance). The third study was an internet survey looking at how early traumatic experience was linked to higher levels of subsequent PTSD when subjects also reported attachment anxiety (with associated reductions in self-esteem and increases in negative self-judgements). Attachment avoidance - with its tendency to see others as "bad" rather than oneself - was associated with lower levels of later PTSD. Other work has suggested that this kind of "competent" attachment avoidance can be quite brittle when external stresses become too great. Possibly this is partly due to over-reliance on self and poor ability to ask for or trust social support. It was interesting later in the day to hear Andrew Gumley and Matthias Schwannauer reporting an opposing pattern in first episode psychosis of increased vulnerability with avoidant attachment as compared to anxious attachment. Anke then went on to report her fourth study which involved work with attachment and intranasal oxytocin - but outcome results weren't yet in. If you're unfamiliar with the attachment literature, there are a series of blog posts on this website that might be worth glancing at. Examples include "Assessing attachment in adults", "Attachment, compassion, and relationships", and "Behavioural systems: attachment (care seeking), care giving, exploration, sex, & power".
The morning ended with Arlene Vetere speaking about "Working within and between: systemic therapy and attachment narratives." This was a broad brush keynote lecture from a very experienced and senior systemic therapist. On the whole it feels good to me that BABCP is occasionally asking clinicians & researchers from other therapeutic schools to talk at our conferences. I wouldn't want too many of these "reports from another country" but they can be stimulating. I like Arlene's line about outdated behaviour patterns as "strategy that has gone past its sell-by date". I liked her distinction too between demand focused, protesting "anger of hope" and dismissing, shutting-others-out "anger of despair". She touched on the work of John Bowlby, John Gottman, Les Greenberg, Susan Johnson, Mario Mikulincer, and others. She talked about social constructionist-narrative practice, attachment theory, and systemic theory and practice, saying that she felt the three approaches needed each other. She commented that it had been easier to research mother-child dyads than more complex systems, but that more work was now emerging on the effects of fathers and siblings. She commented that feminists had battered attachment theory a good deal claiming it was too blaming of mothers. Arlene felt it was important to ask "What supported the mother - in the couple, the family, and the wider social community?" Arlene Vetere is a professor at the University of Surrey. Like many other therapists from a variety of schools, she has been developing applications of attachment theory. Her more recent book "Systemic theory and attachment narratives" looks good. Interesting.
After lunch we had three talks in a Mentalisation and psychosis symposium. Wikipedia states "Mentalization is a psychological concept used by the psychoanalytic psychologist Peter Fonagy; he employs it to describe the ability to understand the mental state of oneself and others based on overt behaviour. Fonagy sees mentalization as a form of imaginative mental activity, which allow us to perceive and interpret human behaviour in terms of intentional mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons)." I don't work much with psychosis and I certainly don't see myself as at all psychoanalytic, so this symposium didn't particularly appeal to me. However I am interested in how my work can be helpfully informed by attachment theory. I note that Wikipedia goes on to say "Mentalization has implications for attachment-theory as well as self-development. According to Fonagy, individuals without proper attachment (e.g. due to physical, psychologial or sexual abuse), can have greater difficulties in the development of mentalization-abilities. Attachment history partially determines the strength of mentalizing capacity of individuals. Securely-attached individuals tend to have had a mentalizing primary caregiver, and resultantly have more robust capacities to represent the states of their own and other people's minds. Early childhood exposure to mentalization can serve to protect the individual from psychosocial adversity." And to give Fonagy his due, he has published interesting research on his mentalization approach - for example, last year's "Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder".
Anyway, the three talks were Dickon Bevington on "Mentalization as an integrative tool: moving from multi-muddle to multi-modal working in an approach for hard-to-reach multi-problem youth: AMBIT", Andrew Gumley on "Telling stories: the importance of narrative coherence and its relationship to outcomes in a prospective study of first episode psychosis" and Matthias Schwannauer on "Mentalisation and reflective functioning in first episode psychosis". Thoughtful, some nice quotes from John Bowlby, some nice Scottish scenery backgrounds to Andrew's initial slides - not really my field though.
Then, after a tea break, we had the "old master" Paul Gilbert talking on "Relating and relationships in CBT: the clinical and scientific importance of a compassionate mind approach" (actually chatting with him, it turns out Paul is a bit younger than me - so maybe he qualifies as "master in the prime of his life" rather than "old master"?). This presentation would definitely have been my highlight of the day, except that I know Paul's work fairly well so most of what was said wasn't new to me. There were good, fresh titbits though. Paul commented how patients often seemed to find it helpful when a parallel was drawn between training the mind in forms of meditation and training the body at a gym. He mentioned research work from Richard Davidson's Wisconsin University Lab for Affective Neuroscience. I love it how the internet allows us to check this kind of stuff out so easily. See, for example, the list of free full text downloadable publications by Davidson and his colleagues. Yes, this work does highlight that meditation "trains the brain". And as an aside, visiting the Affective Neuroscience Lab website gives a link to a new venture at the University of Wisconsin - the "Grand Opening Celebration" next month of the Center for Investigating Healthy Minds, with "honored guests His Holiness the 14th Dalai Lama, mindfulness pioneer Jon Kabat-Zinn, best-selling author Daniel Goleman and Wisconsin Governor James Doyle, among many others." What fun. Life goes on. Paul also talked again about how introducing compassionate mind training can be aversive to people who are chronically self-critical. It reminds me a bit of how asking chronic worriers to worry less can feel threatening for them ("If I don't worry, I won't be ready for the bad things that might happen"). He used a nice analogy that went something like "Kindness opens up the attachment system like opening a book where it was last closed. Then whatever fears, anger, or despair is coded there will become available and can be intensely threatening". The therapeutic work may then involve progressive desensitisation as with other objects of inappropriate levels of fear. Presumably too one may sometimes need a more PTSD memory processing style of approach for some people with particularly toxic early experiences.
Overall a good day. In tomorrow's post I'll talk more about Willem Kuyken's findings on Mindfulness Based Cognitive Therapy and compassion.