Birmingham BABCP conference: second day - NICE, emotion regulation, and exposure with depression & with cycloserine (4th post)
Last updated on 7th November 2014
So yesterday was the second full day of the BABCP conference. I have already written initial blog posts about the first day of the conference and about the pre-conference workshop I went to on emotion regulation. This is a bit of a pre-breakfast scamper over yesterday's experiences. As with the other blog posts I've written about the conference & the emotion regulation workshop, I intend to re-visit the more personally relevant subjects in future posts. As James Bennett-Levy highlighted in his paper last year - "Use it or lose it: Post-workshop reflection enhances learning and utilization of CBT skills" - without this kind of review process almost all the material we're exposed to in conferences is likely to simply get washed away in the busy-ness of our lives. I have written before about some puzzlement I have around the BABCP (an organization that prides itself on it's foundation in science) not being more innovative about the way it runs its conferences.
The path I took through the maze of choices yesterday involved going to a symposium on "NICE guidelines for mental health: Evidence updates", followed by continuing my personal conference theme of exploring how new findings in emotion science might help us become more effective therapists. I went to Dave Fresco's keynote "An emotion regulation framework for emphasising commonalities in cognitive-behavioural treatments", then to Adele Hayes's skills class "Can principles of exposure and emotional processing from the treatment of anxiety disorders apply to treatment of depression?" and finally I listened to Jasper Smits's possibly rather "over-sold" keynote "How to help clients get the most out of therapy". And woven into all this were a whole series of lovely conversations with people I've met at previous conferences and people who I've never met before this visit to Birmingham. Warm, interesting, exploratory, informative ... thank you to everyone who I've spoken to across these fascinating few days.
First the "NICE guidelines for mental health: Evidence updates". I came away from this series of three talks with two main impressions - firstly what a huge societal problem alcohol is, and secondly how "snailishly" we move forward in actually becoming more effective in our work. So the deeply informed, but possibly rather world-weary Colin Drummond from Kings College spoke about the update to guidance on "Alcohol use disorders". His slide on on epidemiology highlighted that alcohol is the 3rd biggest cause of disability in Europe, that 24% of us are drinking at hazardous levels, that 4% of us are alcohol dependent (with a linked 25 year loss of possible life), that adolescent alcohol consumption in the UK has doubled in the last 10 years, that hospital admissions for alcohol-related problems have doubled in the last 8 years, and that it's estimated alcohol costs the NHS 3.5 billion pounds and UK society as a whole 25 billion annually. Couple this with the observation that probably the best evidence-based governmental response is to increase the price of alcohol (which, for years, has been falling relative to our personal purchasing power) but the government appear to have caved in to intense lobbying from the drinks industry and have not followed through on this eminently sensible response to a deeply toxic societal situation. Maybe it's understandable if Colin looks a bit "world-weary". We're bad at identifying problem drinkers - only 1 in 60 harmful and 1 in 20 dependent drinkers picked up in primary care. Mental health services are bad at this too. We should be using screening tests much more routinely with validated tools such as FAST and AUDIT ... see this website's "Good knowledge" page on "Alcohol & food" to download copies of the AUDIT and other alcohol-related handouts. Colin also pointed out that for dual diagnosis clients with alcohol problems and a mental disorder such as depression, we nearly always treat the depression first before getting round to tackling the alcohol difficulty. The evidence apparently suggests we should be doing the opposite - addressing the alcohol problem first and then seeing how much the mental health problem is still evident as the alcohol difficulty (hopefully) eases.
So this was a good "first thing in the morning" wake up call. I personally can certainly get better at responding to this need. Actually there wasn't much in the way of NICE needing to update their guidance on alcohol in the light of new evidence. And this was even more glaringly obvious to me with the subsequent presentations by David Veale on OCD and by Jennifer Wild on PTSD. This was my second major "take-away" from this symposium - the snail pace of improvement in what we can offer clients. David said that the OCD update involved a literature search for the ten years from 2003 to 2013 and ... and ... there was virtually no change in the guideline recommendations. He made some interesting points about caution around augmentation treatments involving antipsychotics, but this isn't big news for most cognitive therapists. Similarly Jennifer Wild's comments on NICE guideline change in the light of new research evidence on PTSD treatment came up with virtually nothing new. OK there is now more evidence to support the use of fluoxetine & venlafaxine for PTSD ... again not headline information for psychological therapists. I talked about all this with a colleague a little later in the day. They optimistically suggested that the guidelines might not have had to update their recommendations for, for example, the use of CBT ... but that the CBT treatment itself might have been getting more effective. Mm ... it's an optimistic point of view. Do read the rather shocking findings from Lars-Goran Ost's meta-analysis of CBT results broken down by decade of publication before settling into this comfortable (and largely incorrect) point of view ... see the 2011 conference report "BABCP spring meeting: the conference - an overview & why no uproar (over Ost's findings)?".
Then I went on to the keynote by Dave Fresco on "An emotion regulation framework for emphasising commonalities in cognitive-behavioural treatments". I have already written fairly extensively about Dave Fresco & Doug Mennin's work in my earlier blog about their "Emotion regulation therapy". This is interesting territory and I suspect one of the most useful things I can do, in this area, is to look at the fine 2014 2nd edition of the "Handbook of emotion regulation" edited by James Gross & involving contributions by over eighty other researchers.
This lecture was followed by lunch and then Adele Hayes's intriguingly titled skills class "Can principles of exposure and emotional processing from the treatment of anxiety disorders apply to treatment of depression?" This was such an interesting couple of hours for me. The sound in the room was poor and it was hard at times to follow what was going on. Quite a few people left before the end, and the evidence-base showing whether this approach actually adds anything to much simpler treatment like behavioural activation is currently poor. And I found it fascinating! Partly this is because I have a lot of trust in major transdiagnostic approaches like exposure and emotional processing, so their application to depression is worth paying attention to - especially as depression is a territory where the dodo-bird hypothesis of therapy equivalence is currently so well supported. Partly too it's because there are a whole bunch of different researchers beginning to look at treatment of chronic (and recurrent) depression (and related disorders) in ways that overlap with Adele Hayes's explorations. So we have Arnoud Arntz extending his schema-based approach for borderline personality disorder to other personality disorders and now also chronic depression. We have Marylene Cloitre's developments of emotional processing for complex trauma. We have Les Greenberg & colleagues' ventures into testing emotion-focussed therapy for depression, and their subsequent integration of EFT with narrative therapy. We have Chris Brewin's work on intrusive trauma imagery in depression. There's a real checking out of new takes on old problems to see if we can move our rather stuck treatment results in depression further forward. When Adele says "The more I work with depression, the more I think it looks like PTSD" we have a really interesting innovative take on this difficult challenge. Great ... I certainly plan to explore this more.
And then coffee and on to Jasper Smits's possibly rather "over-sold" keynote "How to help clients get the most out of therapy". I say over-sold because the title of his talk makes the subject appear rather grand & broad ... a bit like my attempt in a lecture last year entitled "How can we help our clients more effectively?". What he actually talked about mostly was the use of cycloserine to boost the effectiveness of exposure therapy. Actually his points about the importance of really supporting memory processes after new learning has all kinds of interesting implications ... much more broad than just this rather narrow focus on cycloserine. More about this in a subsequent post, but for now it's well worth noting the recent study "Sleep enhances exposure therapy" with its conclusion "Our results indicate that sleep following successful psychotherapy, such as exposure therapy, improves therapeutic effectiveness, possibly by strengthening new non-fearful memory traces established during therapy. These findings offer an important non-invasive alternative to recent attempts to facilitate therapeutic memory extinction and consolidation processes with pharmacological or behavioral interventions."
Time for the last morning of the conference ... see the post "Final morning - positive affect in depression, therapy adverse effects & overall review (5th post)".