Last updated on 2nd August 2010
This year's annual British CBT conference jamboree has been a bit unusual for me. I've been coming to these British Association for Behavioural & Cognitive Psychotherapies (BABCP) conferences for years now, and routinely I would start with one of the full day pre-conference workshops before launching into the three days of conference proper. I was booked into Emily Holmes's "Mental imagery in cognitive-behaviour therapy: PTSD and beyond" workshop, but then poor Catero my wife hurt her back at the weekend and so plans were changed and I delayed coming down from Edinburgh. Recovery proceeds and here I am - a day & a half "late" and checking my mobile for news from home - but here for the first afternoon of the three day conference proper.
I went to a symposium convened by the admirable Ann Hackmann entitled "More news from the imagery front". Ann is a real CBT imagery pioneer, sadly now retiring. It's been lovely to hear her clinical wisdom over the years and to see how fond her colleagues are of her. There were five papers presented - the symposium itself simply one of twelve parallel sessions all running simultaneously from 1.30 to 3.45pm on this first day. To access more details of these talks, see pages 28 to 30 of the 107 page "Conference abstracts" book.
First off was Jon Wheatley on "Imagery rescripting as a stand-alone treatment for depressed patients with intrusive memories". I heard Jon give a similar talk at last year's Exeter conference and there's also a description of his work in Nick Grey's book "A casebook: cognitive therapy for traumatic stress reactions". It was still helpful for me to hear how "respectfully" Jon approached this kind of powerful imagery work with his clients. The images were "often of key defining moments from autobiographical memory such as loss of loved ones, interpersonal crises or childhood abuse". He commented that it was sometimes important to do other more general work with the client before focusing on these very distressing areas. I find it helpful to say to clients something like "The key thing is for you to benefit as much as possible through your therapeutic work here. I think it's very likely indeed that helping with these horrid memories you experience will be of real use for you. However we're not going to look at any of these memories more thoroughly until you're clear why it's likely to be helpful and you feel ready to start working on them. You're in charge and we go at your pace." These very difficult events clients have experienced often leave them feeling helpless victims. Part of therapy is to help them return to feeling worthwhile, competent and more in charge. An authoritarian approach by the therapist is likely to be counterproductive in a whole series of ways. It's easy to be insensitive as a therapist and tramp in, very clear how one wants to work with a particular set of trauma memories. I think it is genuinely helpful to have a pretty strong idea of why a set of memories seems so toxic for a client and how one suspects the memories themselves and the meaning associated with them may need to shift to produce good therapeutic benefits. However it was a useful reminder to hear Jon describing how once clients held the memory - image, sensation, words, feelings - in their attention with all its rawness and emotion, the image/feelings/reactions/judgements might spontaneously change without having to deliberately "rescript" the memory in any way. And even when "rescripting", Jon talked about asking the client questions like "What seems needed in this memory just now?" paralleling the similar respectful questions one might use in "Focusing" such as "What would be a step forward here - even maybe just a small step?" or "What does this feeling seem to need right now?" and so on.
Then Nicholas Page, from London's Institute of Psychiatry, talked on "Imagery rescripting in obsessive compulsive disorder". We were given a glance at this project - with Paul Salkovskis and David Veale - to explore adjuncts for CBT treatment of OCD. As well as an overview of this work, Nicholas also described a memorable case example of someone who had suffered from OCD for decades, and who made impressive treatment gains when imagery rescripting (using methods described in Arnoud Arntz's work) was added to standard CBT. This kind of detail one rarely gets any clear idea of when reading crucial, but somewhat dry, reports of randomized controlled trials (RCT's). We need both. RCT's show us what therapeutic "dishes" are worth eating, but this kind of detailed case presentation shows us how to actually roll up our sleeves and do the cooking.
Kate Muse, from Oxford University, spoke on "Relating differently to intrusive images: the impact of mindfulness based cognitive therapy (MBCT) on intrusive images in health anxiety (hypochondriasis)". This was a spin-off from the trial of MBCT for health anxiety that I described more fully at last year's Exeter conference. Kate reported that "Consistent with findings in other anxiety disorders, distressing intrusive images have been found to affect the majority of patients with health anxiety. Although research exploring the use of imagery interventions has increased in recent years, little is known about the impact of MBCT on intrusive imagery." She suggested that MBCT might be particularly appropriate for distressing images in health anxiety for two reasons. One is that the images are often future focused with a time course of years - in contrast, for example, to panic disorder where catastrophic beliefs focus on what seems to be happening over a time course of minutes - so MBCT's emphasis on changing one's relationship with the images, rather than challenging their content, seems particularly sensible. Secondly Kate said that MBCT helps clients reduce avoidance and rumination, so encouraging more helpful response styles to intrusive images. She presented results from 34 health anxiety sufferers, half of whom received MBCT training. The reported reduction in frequency, associated distress, intrusiveness, and avoidance in the active treatment group was really rather impressive. This outcome makes me think of work showing that prolonged exposure to upsetting memories is often enough therapeutically - see, for example, the study "Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring" - with a companion publication showing as much cognitive change in the exposure group as in the exposure plus cognitive restructuring group - "Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring". It has been argued that simple prolonged exposure is enough where fear is the main emotion involved but that one needs more complex cognitive restructuring techniques when other emotions - like shame, guilt and anger - are prominent. See "Imagery rescripting and reprocessing therapy after failed prolonged exposure for post-traumatic stress disorder". It's an interesting and important debate and, for me, the jury is still out. If one looks at the Foa prolonged exposure trials on rape victims (see above), I don't believe that the associated emotions were only fear. Shame, guilt and anger were also being restructured by the prolonged exposure. This has been illustrated as well in case studies - like Jon Wheatley's above - where spontaneous restructuring of shame/guilt memories has occurred simply through observation, for example, as an adult of how young the abused child actually was and how very clearly they were not responsible for what happened to them. More research please.
The next paper was entitled "Can we dampen down intrusive imagery such as flashbacks soon after a stressful event using simple tasks?" Emily Holmes & colleagues have published before on how competing tasks during trauma exposure can augment or diminish subsequent intrusive images. See for example "The influence of a visuospatial grounding task on intrusive images of a traumatic film". Here they reported on research showing that competing tasks after viewing - rather than during viewing - traumatic film clips can also affect subsequent intrusions. Fascinating. Not probably relevant for my work, but it could become so for casualty workers/departments. Finally Sally Standart, from the North East Traumatic Stress Centre, gave a clinically orientated presentation called "'What if' in imagery". She reported on a series of cases where trauma victims experienced "projective flashbacks" where they were tormented by images of what might have - but actually didn't - occur. Sally suggested that it is important to be aware of the possibility of projective flashbacks as she has found that clients may not spontaneously volunteer their existence and they may not respond that well to simple exposure methods. Interesting and worth bearing in mind when trauma patients aren't responding to therapy as well as one would hope.
I then went to a plenary presentation by Emily Holmes on "Mental imagery: from flashbacks to flashforwards".