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Birmingham BABCP conference: final morning - positive affect in depression, therapy adverse effects & overall review (5th post)

The last morning of this excellent BABCP conference dawned bright & sunny ... as it has all week.  I have particularly enjoyed this year's BABCP get-together.  I think this has been due to a combination of factors including presentations that have been personally of real interest, the weather, the University of Birmingham accommodation, good wifi access(!) and the general friendliness.  Not bad considering I hurt my back in the train on the way here and it has only gradually been easing over the four days of the workshops & conference.  I described the pre-conference workshop I went to in a couple of blog posts beginning with "Emotion regulation therapy with Doug Mennin & David Fresco (1st post)", and then proceeded to write a couple of posts about the conference itself: "First day - decentering, compassion, social anxiety, sp/sr & barbecue (3rd post)" and "Second day - NICE, emotion regulation, and exposure with depression & with cycloserine (4th post)".  This is the third post in this conference description sequence and just covers the final half-day. 

I do get a sense that, at these final mornings of conferences (especially after big social dinners the evening before), we're getting down to a core of diehard enthusiasts.  I was very tempted to go to the clinical skills class with Barney Dunn & Richard Moore on "Learning how to feel good: how to build positivity in depressed clients" with its abstract reading: "Background: The primary focus in CBT for depression has been on down-regulating negative thinking and feeling.  However, it is increasingly realised that anhedonia, a reduction in the ability to experience pleasure, is also central to the onset and maintenance of depression, particularly more chronic presentations. Augmenting positive emotional experience and positive information processing has received less attention in the CBT literature to date.  There is increasing interest in the idea that anhedonia is central to mood disorders and should be more of a focus in treatment. This skills workshop will focus on ways to build positivity in CBT treatment, whilst minimising the possibility that a positive focus is perceived by clients as “PollyAnna-ish”.  A mixture of training modalities will be used, including reviewing session tapes and role-play practice.  Learning Objectives: By the end of the class, participants will have learnt how to: Identify and formulate mechanisms that maintain anhedonia.  Identify and target ‘positive dampening’ appraisals and counterproductive emotion regulation strategies that block pleasure experience.  Optimise use of existing CBT techniques (e.g. activity scheduling, positivity data logs) to build positivity. Minimise the likelihood that a positivity focus is perceived by clients as “PollyAnna-ish”.  References: Dunn, B.D. (2012). "Helping depressed clients reconnect to positive emotion experience: Current insights and future directions." Clinical Psychology & Psychotherapy, 19, 326-340.  Werner-Seidler, A., Banks, R., Dunn, B. D. & Moulds, M. L. (2013). "An investigation of the relationship between positive affect regulation and depression."  Behaviour Research and Therapy, 51, 46-56.  (The abstracts of these papers are available from Barney Dunn's university webpages).  Barnaby Dunn ... leads a research programme characterising positivity deficits in depression and developing novel ways to build positivity in CBT.  Richard Moore ... has extensive experience in providing CBT for treatment resistant depression ... and co-authored “Cognitive Therapy for Chronic and Persistent Depression” with Anne Garland. "Implications for everyday CBT practice: Better targetting anhedonia is likely to lead to improved treatment outcomes when using CBT to treat depression."  It does look an interesting skills class.  However I suspect the issue of "failed therapy" is likely to be even more central in trying to help clients better ... hence my decision to go to the University of Sheffield's team symposium on this.  Maybe the best I can do to get some juice from the positive affect ideas for depression is write to Barney Dunn asking for full text copies of relevant papers by him that I don't already have.

So the symposium I did go to was "Understanding and preventing adverse effects of psychological therapy" with three excellent presenters from the University of Sheffield.  Glenys Parry gave an overview of the talks to follow.  They were on three different studies - one a survey followed by a qualitative study of the experience of therapists and therapy recipients of failed therapy; a second on multi-level modelling to explore predictors of deterioration and drop out in large clinical datasets of outcomes in routine psychological treatment; and the third on a re-analysis of data from randomised controlled trials, comparing a psychological treatment with a no-treatment control, to investigate risk of harm.  Glenys also introduced the excellent linked "Supporting safe therapy" website.  This site is * Aimed at improving the experience of psychological therapy for both clients and therapists.  * Contains evidence-based information and practical tools to enable therapy users to have - and therapists to provide - a safe, effective, and positive experience of therapy.  * Provides information about what should (and shouldn't) happen within therapy.  * Flags up common problems and how they can me managed.  * Gives a balanced view about the benefits & risks of therapy to support people's decisions about whether to enter (or leave) therapy.  Very good.  I would argue strongly that therapists are poor at predicting & detecting client deterioration & dropout.  I would also argue that getting better at managing these issues is one of a comparatively few, obvious, research-highlighted ways of becoming a better therapist (probably a more direct way of becoming a more effective therapist than learning more about almost any therapeutic approach being discussed at this conference).  See the talk "How can we help our clients more effectively?" for more on this.  

Gillian Hardy now discussed the survey study entitled "Learning from therapists' and patients' experience of failed therapy".  The talk's abstract read: "Aims: a) to investigate the accounts of service users and therapists who have reported failed therapies or adverse effects of therapy; b) to explore what they would have found helpful in preventing the adverse outcome; c) to inform a specification of potential tools for clients and therapists and direct how these tools may be used most effectively.  We used a two-stage mixed method design. A survey of therapists and service users was undertaken, identified through service user organisations and professional bodies. This yielded 193 client questionnaires and 322 therapist questionnaires. This was followed by a qualitative study of participants' perceptions of failed therapies (including accounts of what went wrong and how this might have been prevented). The survey sample was opportunistic, followed by purposive sampling to achieve maximum variation in the age, sex, ethnicity and sexual orientation of patients and the type of therapy, drawing on survey participants who had volunteered to be interviewed. Face-to-face (n=10) and telephone interviews (n=30) were conducted, audio-recorded and transcribed for 20 therapists and 20 clients.  Eighteen themes were identified and elaborated from the therapist survey, including client factors, therapist competence, service pressures and constraints, and problems in the therapeutic relationship. Other data are currently being analysed; results will be available from February 2014.  These results enable a rich understanding of the factors which signal risks of adverse effects or harm from therapy, and directly inform tools to support both therapists and clients in achieving safer therapy."  One slide she showed had the heading "What might help?" and listed three clusters of factors: Firstly * Clear information, choice and decision making.  * Supportive service structures.  * Genuine assessment (leading to a plan).  * Clarity about sessions and progress.  Then: * Managing expectations.  * Core therapy skills.  * Practical solutions.  * Social support and safety.  * Respect and validation.  * Empowerment.  And finally: * Opportunities for feedback.  * Complexity and competence.  * Vigilant for signs of deterioration.  Good stuff!

Dave Saxon then spoke about "Risk factors for reliable deterioration during therapy and unplanned therapy endings" with his abstract reading: "To assess the rate and predictors of client deterioration and unplanned endings in psychological therapies, using large datasets from routine practice. The UK CORE National Database consists of nine years of CORE outcome measure data (1999 – 2008), from psychotherapists and counsellors in differing sites and settings across the UK. Reliable deterioration was defined as a pre-post increase in CORE-OM score of 5 points or more. Hierarchical linear modelling enabled data to be analysed by site and therapist.  Of the 26,130 completer clients in the dataset, 335 (1.3%, 95% CI: 1.2, 1.4) experienced statistically reliable deterioration. The proportion of clients per therapist showing reliable deterioration ranged from 0.24% -15.8%. Being unemployed or on welfare benefits was a strong predictor of reliable deterioration. Other predictors of reliable deterioration were chronicity (problems for over a year), caseload and Black or Minority Ethnic status. Approximately 25% of clients who received two or more sessions of treatment had an unplanned ending (N=41,342). There was considerable variability between therapists in rates of unplanned endings (range 0% to 71.2%). Unemployment, ethnic minority status, younger age, and client complexity were predictive of unplanned endings. Smaller change from first to last session may also be a factor.  The wide variation between sites and therapists is striking. It demands greater awareness in service managers and therapists of risk factors for deterioration or dropout, including service factors, e.g. caseloads, client complexity, which signal need for therapist support."  I personally found this talk the most interesting of the three.  It was fascinating & sobering to see the large variation between therapists in both deterioration and dropout rates on Dave's intriguing "caterpillar charts".  Very interesting to see on his "scatterplot" that these were two largely separate phenomena, so one therapist might have high dropout but low deterioration rates, while another might have the reverse.  Mostly it's likely to be best to have both low dropout and (obviously) low deterioration rates.  In the study that Dave showed us, these "double star" therapists didn't seem that common.

And then third in line, Glenys Parry talked about "Risk of harm in psychological therapies: a re-analysis of deterioration data from randomised controlled trials" with the abstract reading: "To investigate the risk of harm in psychological therapies by comparing deterioration rates in randomised controlled trials of psychological treatments with control groups receiving no psychological treatment. Inclusion criteria were a) randomised trials of psychological treatment; b) analysed by the UK National Institute for Health and Care Excellence (NICE) as the basis for their clinical guidelines; c) in depression, anxiety or PTSD; c) which included a comparison with a ‘no psychological treatment' control group. Principal Investigators of these trials were approached and asked to provide their full dataset for re- analysis as part of the AdEPT project. This yielded 16 study datasets (11 Depression, 3 GAD, 2 PTSD; total N= 992), which were assembled into a single dataset and analysed using STATA.  For each included study the proportion of people who deteriorate in the treatment arm was compared to the proportion which deteriorates in the control arm. These and their confidence intervals were then combined using meta-analytic techniques, to produce an overall relative risk of deterioration from treatment. A number of analyses were undertaken to accommodate the diversity of populations, treatments, measures and measurement points, and a pre-post deterioration 0.5 SD was defined as reliable.  Of the 16 studies, seven showed a higher rate of reliable deterioration in the active treatment group, but 95% confidence intervals included a ‘no difference' result in all but one study. Overall, meta-analyses found no evidence that deterioration rates systematically differ between treatment and control groups."

A very worthwhile symposium, and bookmarking the "Supporting safe therapy" website & guideposting both clients & fellow therapists to it makes great sense in the future.  Sadly I didn't stay for the final keynotes as I had a train to catch back up to Edinburgh ... and the waiting grandchildren!

Just time for a quick 'overview'.  As I said in a first post on the conference proper, " ... the conference offers 37 symposia, 5 panel discussions, 3 clinical roundtables, multiple poster sessions, 13 skills classes, numerous special interest group & branch meetings, & 18 keynote addresses - all over the course of two & a half days here on the University of Birmingham campus.  The freely downloadable 101 page abstracts book gives a great sense of what's on offer.  It regularly strikes me - when attending these big multi-track conferences - that it would be very possible to come with several colleagues and all end up going to totally different sets of presentations.  The conference is a buffet of choices and part of the challenge is to construct a personal "academic meal" that will really feed our own particular work & intellectual needs."  I also think that it's scarily easy to come to conferences such as this, be stimulated by a whole set of new ideas & research findings, go back to the busy-ness of one's everyday life and then ... just a few weeks later ... have forgotten almost everything one heard and have found that it has had no measurable benefit on one's work.  To combat this tendency, it seems very important to continue to think about, explore, develop & try out the new input one has been impressed by.  

So what do I want to continue to explore & try out?  Well the workshop I went to on "Emotion regulation therapy with Doug Mennin & Dave Fresco" has nudged me into getting hold of the rather expensive & rather wonderful 2014 2nd edition of the "Handbook of emotion regulation" edited by James Gross.  So one post-conference intention I have is to look through this book more thoroughly and continue to develop some of the ideas & interventions that it explains.  A second intention is to integrate insomnia treatment still more regularly into my work with a wide variety of disorders. I was very impressed by Colin Espie's talk on insomnia on the first day of the conference proper and his website www.sleepio.com is excellent. As a therapist, one can dovetail with this service, monitoring how one's clients are doing with the sleepio insomnia programme as well as receiving useful research updates and the opportunity to discuss relevant issues with colleagues.  I plan to develop my interaction with sleepio further and explore how useful it is to monitor how clients are doing with the insomnia programme.  Still on the first day of the main conference, there was the great skills class with Jennifer Wild on "Optimising video feedback for social anxiety disorder: Face-to-face and virtual techniques".  I said I would write a whole blog post about this skills class later and I aim to do that.  The final keynote I went to that day was James Bennett-Levy's talk on self-practice & self-reflection (SP/SR).  I have been asked to write a chapter in a forthcoming book on SP/SR so that should really help me get my act together better in this area.  

I took rather less away from the second day of the conference.  I certainly found Colin Drummond's NICE talk on "Alcohol use disorders" a helpful reminder of the huge amount of suffering associated with alcohol problems and how important it is for all of us to be more on the lookout for these difficulties.  Then there was Adele Hayes's skills class "Can principles of exposure and emotional processing from the treatment of anxiety disorders apply to treatment of depression?" and her intriguing remark "The more I work with depression, the more I think it looks like PTSD".   Her work overlaps so interestingly with developments by Arntz, Brewin, Cloitre, Greenberg and others.  I want to continue to explore the relevance of trauma processing and developing positive affect networks in these kinds of disorders - see, for example, earlier posts on "Imagery, associative networks, embodied cognition and the transformation of meaning" and "Our minds work associatively: this is of central importance for psychotherapy and for life in general".  Then there was the second day final keynote that I went to ... Jasper Smits's presentation on "How to help clients get the most out of therapy". I've described this talk as a bit "over-sold" as it focused particularly on using cycloserine to boost the effectiveness of exposure therapy.  There were however several useful 'reminder points' that emerged from the talk: 1.) adding medication to exposure therapies typically only very modestly increases response rates and (at follow-up) may result in poorer exposure outcomes once the medication is withdrawn.  2.) when combining medication & exposure, a key issue is likely to lie in what the client credits for any improvement they achieve.  If they give much credit to the medication, then they're likely to struggle when the medication is withdrawn.  3.)  context does seem to be important with exposure, so clinically it makes good sense to vary contextual factors e.g. with & without the therapist, both inside & outside the therapy room, using a wide variety of exposure challenges, etc.  4.) strong memories of overcoming fear promote more successful longterm outcomes, so make successful exposure more memorable e.g. using cycloserine, by 'broadening the bandwidth' & using exposure to challenging situations over & above anything the client is likely to face in daily life, by taking photos or videos (or providing other mementos), and by strong praise.  Then there was the final morning's input on adverse effects and the excellent "Supporting safe therapy" website.  

So overall, this year's BABCP conference felt personally very worthwhile ... particularly if I conscientiously follow up key areas that look potentially productive therapeutically.

 

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