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Leeds BABCP conference: 2 symposia on how CBT works, Paul Salkovskis plenary, the compassion special interest group (5th post)

This year is the 40th annual British Association for Behavioural & Cognitive Psychotherapies (BABCP) conference and it runs for for three full days plus the option of a one day pre-conference workshop.  I've already written about the pre-conference workshop I attended on "Chronic fatigue" with Trudie Chalder.  Despite the fact that the main conference typically provides a choice of 16 or so simultaneous symposia, panel discussions or skills classes, there didn't seem to be a huge amount on this first day that was immediately clinically relevant to my work with adults who are usually suffering from problems with depression and anxiety.  I ended up going to a symposium in the first half of the morning on "How does CBT work?  Exploring multiple factors" and in the afternoon on "How does CBT work? Mechanisms of change 'across the waves'".  At the end of the morning I went to a plenary by Paul Salkovskis on "A better understanding of how the world works?  An integrated perspective on how psychological treatment is effective with particular reference to the current status of understanding and treatment of OCD".  I didn't get to the afternoon plenaries as I was doing a bit of preparation for the first meeting of the "Compassion Special Interest Group (SIG)".  Chatting at the meals was fun too.  I bumped into Mark Freeston on the way to breakfast and had a slightly egg & beans distracting conversation at around 7.30am about his recent research on intolerance of uncertainty.

Then to the first two hour symposium on "How does CBT work?  Exploring multiple factors".  Fascinating to see the hugely different material presented at the four talks that were given.  A bit like going to the zoo and walking past the elephant enclosure to find oneself in the small mammal house!?  Rob Dudley, from Newcastle, was convening the meeting.  He introduced a talk by Philippa Garety of London's Institute of Psychiatry.  She presented details of a large multi-centre intervention - the "Prevention of relapse in psychosis (PRP)" trial.  She said something like "Involvement in this trial has consumed much of my waking thoughts for a decade".  Elephant material.  The paper presenting the straightforward results, with Philippa as lead author, was published in the British Journal of Psychiatry in 2008 - "Cognitive--behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: Randomised controlled trial."  Basically, after vast amounts of development work and then the huge effort of the expensive, multi-authored, multi-centred trial the CBT intervention appeared to have pretty much no effect.  "Character building" said Philippa.  Yes and maybe a bit heart-breaking too.  However when they drilled down into the data more carefully, they did start to find some encouraging and interesting material.  Treatment of psychosis isn't my field but I hope I can recognise dedicated fine work when I see it ... and this major endeavour certainly seemed to qualify.  So this year's paper - "Effective elements of cognitive behaviour therapy for psychosis: Results of a novel type of subgroup analysis based on principal stratification" - reported "In a planned analysis, we applied principal stratification (involving structural equation modelling with finite mixtures) to estimate intention-to-treat (ITT) effects for subgroups of participants, defined by qualitative and quantitative differences in receipt of therapy, while maintaining the constraints of randomization. RESULTS: Consistent delivery of full therapy, including specific cognitive and behavioural techniques, was associated with clinically and statistically significant increases in months in remission, and decreases in psychotic and affective symptoms. Delivery of partial therapy involving engagement and assessment was not effective. CONCLUSIONS: Our analyses suggest that CBT-P is of significant benefit on multiple outcomes to patients able to engage in the full range of therapy procedures. The novel statistical methods illustrated in this report have general application to the evaluation of heterogeneity in the effects of treatment."  Fascinating.  I don't know a lot about treatment of psychosis, but I take away a couple of lessons.  One is the probable crucial importance of client "orientation".  Research findings from the quite separate group psychotherapy field also highlight the great value in taking a good deal of trouble over orientation ... really talking over with the client what is likely to be involved in helpful treatment and what this is likely to demand of them in active participation.  And secondly it underlines for me the importance of monitoring client engagement so one can troubleshoot disengagement quickly.  For more on this see the blog post "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent & potentially dangerous" and the therapist feedback section in "Update on website traffic: my own favourite top 15 ... ".  After this came a couple of smaller symposium talks that grabbed me less, and a final thoughtful "discussant" presentation by Mark Freeston.

Then coffee and off to the larger-than-life (in multiple ways) Paul Salkovskis and his plenary talk on "A better understanding of how the world works? An integrated perspective on how psychological treatment is effective with particular reference to the current status of understanding and treatment of OCD".  I've heard Paul talk & give workshops intermittently over many years.  I personally find him brilliant, loud, helpful, irritating, delightfully clear & at times unnecessarily confrontative.  For me his interpersonal style, on balance, gets in the way of being able to really appreciate the content of what he's saying (in contrast to the quieter styles of say David Clark or Anke Ehlers).  This is a pity.  I fear being insensitively over-certain may be something I can slip into too.  Watch and learn ... the FIG JAM trap ("F*k I'm great, just ask me.").  I certainly find his clarity very appealing, although I occasionally think of the saying sometimes attributed to Goethe - "To be uncertain is uncomfortable.  To be certain is to be merely ridiculous".  And Paul made a series of points that interested me.  Three that stood out are: 1.) It's easy & pretty traditional to describe the mechanism behind the persistence of compulsive behaviours as a reward-seeking response.  For example, I might become bothered by an intrusive obsessive thought or worry.  I feel anxious or otherwise upset.  I perform some kind of compulsive behaviour in response ... that results in reduced distress ... so I'm "rewarded" for the compulsive behaviour and will be more likely to repeat it on a subsequent challenge.  Paul said something like "No, no, this isn't how it works at all.  The intrusions are given a 'meaning'.  The meaning leads to both anxiety/distress and compulsive behaviours.  However the behaviours are best conceptualised as goal-driven activity in response to the threat perceived to come from current (mis-)understanding of the situation".  Yup, that makes sense ... although I wonder what data backs up his assertion.  2.) Distinction between safety-seeking behaviours (SSB's) (considered to be an important factor in anxiety disorder maintenance) and approach-supportive behaviours (ASB's).  This discussion was a theme running through the conference as Adam Radomsky was over here from Canada and giving a plenary talk entitled "A kinder, gentler CBT for anxiety disorders: The potential for safety behaviour use in treatment".  This is based on Adam's research reported and discussed in papers like "Safety behaviour does not necessarily interfere with exposure therapy" and "Anxiety-control strategies: Is there room for neutralization in successful exposure treatment?" .  So Paul argued that safety-seeking behaviours (SSB) buy into the dysfunctional view that an excessively anxiety producing behaviour is significantly dangerous (i.e. encourage avoidance and sabotage behavioural disconfirmation of catastrophic thinking) while approach-supportive behaviours (ASB's) buy into the more functional view that the targeted behaviour is not genuinely particularly dangerous and the problem is due to the excessively catastrophic anxious beliefs (thus promoting disconfirmation of dysfunctional beliefs).  ASB's support progressive approach behaviour rather than persistent avoidance behaviour.  This distinction may, in my experience, sometimes feel a little tricky to tease out in clinical practice, but it still feels helpful overall.  3.)  The third point Paul made that I take away is his emphasis that "disproving the dysfunctional belief isn't enough" in anxiety disorders.  He argued that it is important that the sufferer is also provided with an alternative more constructive explanation that a.) matches up well with past experience, and b.) works well when tested out in behavioural experiments and 'real life'.  Good stuff.  This all felt useful. 

In the afternoon I went to a panel discussion "How does CBT work?  Mechanisms of change 'across the waves'".  The abstract read "Iris Engelhard (Utrecht University, Netherlands) will be proposing that behavioural conditioning can account for change in CBT.  Kelly Wilson (University of Mississipi, USA) will present a 'third-wave' behavioural account based on functional contextualism.  Paul Salkovskis (University of Bath, UK) will propose a cognitive account of the change mechanism.  Tim Carey (Centre for Remote Health; Darwin & Flinders University, Australia) will present an account of change based on a self-regulatory framework known as perceptual control theory."  For me the debate was a mixture of robust discussion, slapstick and frank rudeness that generated more heat than light.  A pity and a personal puzzle too ... how to debate in this kind of situation and produce something useful.  I guess it might come down to a deep and broad understanding of the research literature and an ability to articulate this understanding in a way that's very clear and clinically helpful ... stated with an appreciation of other people's positions, but with assertiveness - neither being a sledgehammer nor a doormat.  Interestingly a link to a recording of this panel discussion has been posted on the "CBT Cafe" at http://www.babcp.com/cafe/index.php?topic=3022.0 and the ACT SIG at http://actsig.wordpress.com/2012/06/27/how-does-cbt-work-panel-discussion-babcp-2012/

I then needed to miss the final set of plenary lectures to go to the first meeting of the BABCP Special Interest Group (SIG) on Compassion.  I've been "carrying" this initiative over the last year and here - at the BABCP main conference - is a perfect time to meet up with others to discuss the way forward.  Twenty or so of us met for over an hour to talk about our hopes & interests.  We managed to assemble a committee of generous volunteers to take the SIG forward.  Great.  I look forward to seeing what emerges over the next year and I intend to keep providing monthly updates of relevant emerging research on Compassion in its many guises. 

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