Birmingham BABCP conference: pre-conference workshop on emotional regulation therapy with Doug Mennin & David Fresco (1st post)

Well ... here I am again at one of the British Association for Behavioural & Cognitive Psychotherapies (BABCP) annual summer conferences.  It's before breakfast on the first morning and I'm a bit wrapped in a funny mix of feelings.  It's about 6.30am on a stunning morning.  The view from my room is of a lovely sun-splashed green lawn leading to a lake.  I'm really looking forward to the conference too.  It's got all kinds of goodies in it. Fascinating.  But in the train on the way down from Edinburgh yesterday, I 'tweaked' my back.  It stiffened up overnight and when I first got going this morning, I wondered if I was going to be able to make it to the conference today.  Well, it seems to be loosening up.  Dignified cautious posture & movements are on the menu just now.  It seems like there's a good chance it will progressively ease over the next few hours.  Fingers crossed!

So today is for pre-conference workshops.  Initially there was an extensive choice of nineteen full day workshops.  There are still eighteen options ... I see from the information sheet I was given last night that one workshop has been cancelled.  Happily not the one that I booked in for - "Emotion regulation therapy" with Doug Mennin from the City University, New York and David Fresco from Kent State.  The workshop publicity reads: Despite the success of cognitive behavioral therapies (CBT) for emotional disorders, a sizable subgroup of patients with complex clinical presentations fails to evidence adequate treatment response.  To address these challenges, contemporary CBTs, focusing on metacognition, mindfulness, and acceptance (e.g., MBCT, ACT, DBT, ABBT, MCT, CFT) have been developed and have begun to show efficacy for complex conditions such as chronic generalized anxiety and major depression. Generalized anxiety and major depressive disorders (often termed “distress disorders”; e.g., Watson 2005) are commonly comorbid and appear to be characterized by temperamental features that reflect heightened sensitivity to underlying motivational systems related to threat/safety and reward/loss. Further, individuals with these disorders tend to perseverate (i.e., worry, ruminate) as a way to manage this motivationally relevant distress and often utilize these self-conscious processes to the detriment of engaging new contextual learning. Emotion Regulation Therapy (ERT) is a theoretically-derived, evidence based, treatment that integrates principles from traditional and contemporary cognitive behavioural treatments (e.g., skills training & exposure) with basic and translational findings from affect science to offer a blueprint for improving intervention by focusing on the motivational responses and corresponding regulatory characteristics of individuals with distress disorders. Open and randomized controlled psychotherapy trials have demonstrated considerable preliminary evidence for the utility of this approach as well as for the underlying proposed mechanisms. In this workshop, attendees will learn to help clients to 1) expand their understanding of anxiety and depression using a motivational and emotion regulation perspective; 2) cultivate mindful awareness and acceptance of sensations, bodily, responses, and conflicting emotions; 3) develop emotion regulation skills that promote a distanced and reframed meta-cognitive perspective; 4) apply these skills during emotion-based exposure to meaningful behavioural actions and associated internal conflicts to taking these actions; and 5) build a plan to maintain gains and take bolder action despite the ending of the therapeutic relationship.

Learning objectives: * Expand one’s understanding of anxiety and depression using a motivational and emotion regulation perspective; * Increase familiarity with ERT skills designed to promote mindful awareness and emotion regulation: * Learn how these skills can be used during emotion-based exposure to meaningful behavioural actions and associated internal conflicts to taking these actions.

The training modalities in this Workshop will be lecture, demonstration, skills training, role-play, video

Clinicians who attend this workshop will be better able to treat a refractory group of clients (clients with comorbid chronic anxiety/depression, those who are highly “emotional” and continuously perseverate). They will be able to better identify the emotional experiences of their clients and aid clients in doing so “on the spot” in their everyday lives.  They will learn tools to impart to their clients to strengthen abilities to become more flexibly aware of their emotions, to manage them more effectively, and to engage more thoughtful actions as a result of this emotional clarity and regulation. Overall, clinicians will become more comfortable working with a difficult group of clients and feel more confident in engaging with emotions in sessions with these clients.

Over the past fifteen years, Dr. Douglas Mennin has developed an active program of research in clinical trials and basic research into the nature of mood and anxiety disorders. While on faculty at Yale, he was also Director of the Yale and Anxiety Mood Services (YAMS), where he conducted trial research and supervised students in conducting empirically based treatments for refractory cases with mood and anxiety disorders.  Dr. Mennin has conducted a number of studies of the basic physiological mechanisms of generalized anxiety and major depression and has recently been examining the role of worry and rumination in maintaining and exacerbating immunological processes such as chronic inflammation. He has also developed and evaluated an emotion regulation-based intervention for generalized anxiety and depression that was funded through an NIMH R34 mechanism. In a series of open trials and RCTs, this approach has yielded very strong effects in treating typically refractory disorders. Further, this work has identified a number of cognitive, physiological, and neural mechanisms that may mediate symptomatic outcome. He has also recently adapted this approach into a web-based training, which is currently being applied to caregivers of patients with cancer. Dr. Mennin’s role on these projects has been to further develop this emotion-regulation based CBT as well as to train and supervise protocol therapists at the performance sites on both procedures of treatment and assessment. In both applied and basic research, Dr. Mennin has trained numerous graduate students and post- baccalaureate research assistants on diagnostic and physiological assessment and mentored them on the development of independent studies that were routinely presented at national conferences or published.  To date, in addition to publications listed below, this line of work has yielded an authored book with Guilford (Mennin & Fresco, under contract), one of the inaugural “spotlight presentations” at the annual meeting of the Association for Behavioral and Cognitive Therapies, and numerous invited addresses.

David M. Fresco is an associate professor of psychology at Kent State University and adjunct associate professor of psychiatry at Case Western Reserve University School of Medicine. He directs the Psychopathology and Emotion Regulation Laboratory (PERL) and is a Co-Director of the Kent Electrical Neuroimaging Laboratory (KENL). He received his PhD from the University of North Carolina at Chapel Hill and completed a postdoctoral fellowship at Temple University. His program of research adopts an affective science perspective to the study of anxiety and mood disorders. Working at the interface of cognitive behavioural and emotion regulation approaches, he conducts survey, experimental, and treatment research to examine factors associated with major depressive disorder (MDD) and generalized anxiety disorder (GAD) including metacognitive factors (e.g., explanatory flexibility, decentering, rumination, worry), peripheral psychophysiology, and emerging work from affective neuroscience, utilizing neuroimaging and electrophysiological techniques. Another focus of the PERL lab is the development of treatments informed by affective and contemplative neuroscience findings that incorporate mindfulness meditation and other practices derived from Buddhist mental training exercises. Much of Dr. Fresco’s NIH-funded treatment research has focused on the infusion of mindfulness into Western psychosocial treatments. He is presently Associate Editor for two journals, the Journal of Consulting and Clinical Psychology and Cognitive Therapy and Research. He is also a frequent reviewer for the Interventions Committee of Adult Disorders (ITVA) of the National Institute of Mental Health.

References/further reading:  * Fresco, D. M., Mennin, D. S., Heimberg, R. G., & Ritter, M. R. (2013). Emotion Regulation Therapy for Generalized Anxiety Disorder. Cognitive and Behavioral Practice, 20, 282-300. doi:10.1016/j.cbpra.2013.02.00.
* Mennin, D. S., & Fresco, D. M. (2013). What, me worry and ruminate about DSM-5 and RDoC?: The importance of targeting negative self-referential processing. Clinical Psychology:  Science and Practice, 20, 259-268.
* Mennin, D. S. & Fresco, D. M. (2014). Emotion Regulation Therapy (pp. 469-490). In J. J. Gross (Ed.) Handbook of Emotion Regulation, 2nd Ed. New York: Guilford Press. 

European positive psychology conference in Amsterdam: self-determination, positive aging, and the economic crisis (4th post)

I have already written three blog posts about early July's 7th European Conference on Positive Psychology in Amsterdam ... firstly on pre-conference workshops "Positive supervision and positive relationships", then on "Love, national happiness comparison tables, & life satisfaction assessment" and most recently on "What proportion of well-being is genetically determined?"

After lunch on the first full day of the conference, I was faced with choosing from fifteen different workshops, symposia & paper sessions.  I picked a "paper session" on "Self-determination theory (S-DT)".  S-DT is a bit of a passion of mine ... absolutely central to my clinical and personal understanding of eudaimonia, well-being & positive psychology.  Clicking on "self-determination" in this website's "tag cloud" brings up nearly thirty or so blog posts & other entries, including the straightforwardly named "Self-determination theory" which gives links to a number of relevant handouts.  Despite my enthusiasm, or maybe partly because of it, I found this paper session rather disappointing.  We had four presentations.  The first was about a really rather interesting sounding research study on couples, but it still seemed to be in the design stage and we weren't given any actual results ... tantalising & a bit frustrating.  Then there was a presentation linking autonomous motivation & appreciative inquiry.  Interesting but, for me, not particularly "solid" ... although I did enjoy a quote from the photographer Jan Somers encouraging understanding through dialogue, that went something like "Wisdom is not to be found between the ears, but between the noses." A third presentation looked at integrating hedonic and eudaimonic research through longitudinal analysis.  It discussed links over three years and emphasised the way these two aspects of well-being tend to be mutually supportive ... especially around relatedness (an echo of Barbara Fredrickson's earlier remark about "do-good" encouraging "feel-good" and vice-versa).  Finally the behatted Frank Martela from Finland spoke on "Elements of meaning in life: Autonomy, competence, relatedness, and benevolence as the four needs of meaningfulness".  He had apparently been doing this research with Richard Ryan, one of the two originators of self-determination theory.  Interesting stuff suggesting that we should add benevolence to the other three extensively researched S-DT needs of autonomy, competence & relatedness.  I have written to Frank to try to get hold of a copy of his slides and the benevolence scale that he and Ryan have developed.  It fits in well with a book that I read during the conference and in the airport/on the plane on my way home ... Alan Grant's "Give and take". 

The next port of call after the "Self-determination" session was another one out of fifteen choice ... this time I selected a symposium on "Positive aging as a function of self-perceptions of aging and dying".  Three of the four presenters were from the Interdisciplinary Department of Social Studies at Bar-Ilan University in Israel.  They shared interesting work.  The symposium began with the non-Bar-Ilan researcher, Yuvai Palgi, speaking about a study involving 1073 older subjects entitled "How do subjective age and subjective closeness to death interact in regulating self-rated successful aging?"  The take-home message seems to be that we tend to feel considerably younger than our biological age (typically about 13 years younger) and we tend to over-estimate how long we're likely to live ... and that both these "distortions" seem to promote more successful (self-rated) aging. Ah, the power of positive illusions!  Actually, in defence of these so-called positive illusions, Palgi pointed out that actuarial tables typically only take into account age & gender, whereas subjective estimates of how much longer one is going to live take in a much more complex web of information. Further presentations covered "The will to live and subjective life expectancy in older adults", "Can ageists age successfully?  Age and death anxieties are negatively related to self rated successful aging through ageism" and "Attachment patterns moderate the relationship between subjective closeness to death and meaning in life."  

The second study here on "ageism" reminds me of how typical it is that members of groups who are judged negatively in broader society (for any of a large number of reasons e.g. gender, mental health, sexual preference, race, employment status, disability, age, and so on) ... that members of these groups can unconsciously internalise these prejudices against themselves.  There is much research on this, for example "On the self-stigma of mental illness: stages, disclosure, and strategies for change" and "The relationship between experiences of discrimination and mental health among lesbians and gay men: An examination of internalized homonegativity and rejection sensitivity as potential mechanisms."  Happily the commonness of this phenomenon means that there has been a good deal of interest in how to counteract these internalised self-prejudices ... and this work would almost certainly have relevance too to those struggling with self-ageist prejudice ... see, for example "Empirical studies of self-stigma reduction strategies: A critical review of the literature."  Interestingly forms of writing can be helpful here ... a fact that I find helpful to remember in my work as a therapist when helping people with self-stigma ... see, for example "Expressive writing for gay-related stress: psychosocial benefits and mechanisms underlying improvement" and "Addressing achievement gaps with psychological interventions".

The last paper in the symposium on attachment patterns and aging actually triggered my interest most because of a throwaway line from the presenter about the particularly toxic long-term effects of avoidant attachment patterns.  This was news to me so I approached the lecturer, Yoav Bergman, at the end of the talk to ask about the evidence underlying his statement.  He cited a book he said he & colleagues treated somewhat like a "bible" in their field ... Mikulincer & Shaver's 2007 publication "Attachment in adulthood: structure, dynamics, and change".  Well I went ahead and ordered a copy of the book.  It's great, but I'm still not a lot wiser about why Bergman made his remark.  I've emailed him to take the topic a bit further.  Possibly he bases his comment on the finding that anxious attachment styles seem to have a tendency to diminish somewhat as we age, whereas avoidant styles seem to persist more enduringly.  It will be interesting to see if he replies and what he has to say further about this issue.

And then, after a coffee break, on to the day's closing keynote lecture "Economic crisis, wellbeing & sustainability" given by a pair of presenters, Dora Gudmundsdottir & Nic Marks.  Nic quoted the Nobel prize winning economist Joseph Stiglitz's clear warning "What you measure affects what you do.  If you don't measure the right thing, you don't do the right thing."  And if you want this point underlined with clear, deeply thought through detail, see the 291 page Stiglitz/Sen/Fitoussi paper "Report by the commission on the measurement of economic performance & social progress". Nic & Dora's presentation was an important part in a rich strand running through the whole conference which focused on national & world issues that emerge when we start to question how we can encourage wellbeing globally.  Wonderful to be at a conference where there are fine presentations and discussion spanning genetics, individuals, organizations, nations & the world.

For the fifth & final blog post about this excellent Positive Psychology conference, see "Flourishing, science backbone & harmonious or obsessive passion"

Treating social anxiety disorder: still more on video (and still) feedback (7th post)

I recently wrote a post on using video in the most effective treatment we have for social anxiety ... "Treating social anxiety disorder: video (and still) feedback (6th post)".  Typically with social anxiety there are several "layers" to a sufferer's fears about potential negative judgements from others. For example they might be anxious that 1.)  They will blush.  2.)  Other people will notice that they are blushing.  3.)  They will then be judged negatively for blushing.  CBT treatment aims to reduce this anxiety by showing sufferers that their fears are exaggerated and that the methods they have developed for managing their difficulties are mostly making the problem worse.  David Clark, the key figure behind the development of this CBT approach, comments that "You are unlikely to get people to buy into these ideas just by talking ... it seems that it is actively experiencing & feeling this stuff that helps." 

Early in the course of treatment, therapists should aim to set aside a full session for an important videoed role play experiment.  Typically this session would occur after assessment interviews and after an individualised model has been developed with the client tracing out on a "flow chart" how their social anxiety episodes usually develop.  The videoed safety behaviours experiment aims to show clients in a very practical, experiential way that the methods that they are using to manage their anxiety (self-focused attention, self-evaluation, and 'safety behaviours') do NOT result in a better 'presentation' to others.  In fact these 'coping techniques' tend to make the situation worse, both for the sufferers' internal experience and for how they come across socially.  This is a big claim, and backing it up with genuine videoed evidence can be game-changing.

The "Social anxiety safety behaviours video experiment form" (Word doc or PDF file) can be used to pre-plan what the client will do & what will be assessed in the two stages of the experiment.  If one is using an assistant/stooge then they are NOT told beforehand what the client's particular fears are and they are asked to treat the role play as a "normal interaction with a stranger".  After the first part of the exercise the assistant is asked to jot down how they experienced the meeting ... "What was your impression of this person (the client)?  How did you find the meeting with them?" At this point the assistant hasn't been informed what the client is specifically worried about.  They are then asked to make more specific ratings of the client's particular concerns e.g. how was the quality of the conversation and/or how intense did the anxiety signs appear?  

Meanwhile, in the first stage of the experiment, the client has been asked to really focus on themselves, how they're feeling, and how they sense they're coming across (high levels of self-focused attention & self-evaluation) and to maximise their use of key pre-agreed safety behaviors (this might, for example, involve them tracking/planning their conversation to constantly monitor if it is witty and interesting enough, or to do one's best to avoid eye contact and keep still, etc).  It is also agreed beforehand what it will be most personally relevant to assess.  This might include both how anxious the client feels and how anxious they estimate they are looking.  It might include objective predictions about how bad anxiety signs will be (e.g. expected blushing severity pinpointed on a paint colour chart, predicted hand trembling or extent of shaking voice physically demonstrated by the client, etc).  It might also include predictions about general appearance and about various aspects of social competence.  The "Negative self-portrayal scale" can often be helpful in highlighting what to assess, as too can information from the "Social anxiety flow chart" - both these measures should have already been completed before getting to the treatment session where we introduce a video experiment.  Similarly the flow chart and measures like the "Subtle avoidance frequency examination (SAFE)" can also highlight what safety behaviours the client is to maximise and minimise during the two phases of the experiment.  

Now one runs through the first phase of the videoed experiment with high emphasis on the client self-focusing, self-evaluating, and using safety behaviours. The assistant/stooge then answers the general questions about their experience of the interaction (before knowing anything about the client's particular fears) ... see the "What was your impression of this person?  How did you find your interaction with them?" side of the "Social anxiety safety behaviours video experiment form" ... and then answers the more specific 0 to 100 severity level questions on the other side of the form.  It may be helpful for the assistant to leave the room for a few minutes now.  The client is asked to answer the phase one 0 to 100 severity questions.  They are then reminded that now, in the coming second phase of the experiment, the request is to reverse their normal methods for coping with their anxiety.  For example, one can ask them to "Try to be much more as you would with someone you’re close to & feel comfortable with, body posture more open, focused on the conversation not oneself, both more interested in the other person & more self-disclosing."  See the recent paper by Voncken & colleagues - "Socially anxious individuals get a second chance after being disliked at first sight: The role of self-disclosure in the development of likeability in sequential social contact" - for more on this.  They are also asked to stop using their typical safety behaviours.  

Now the assistant/stooge is brought back in for the second phase of this videoed experiment.  They and the client have a further short five minute or so conversation.  This time however the client is doing their best to focus out and really get involved with the conversation, while dropping their typical safety behaviours as much as possible.  At the end of the conversation, the assistant is again asked to rate the various pre-identified targets (e.g. how anxious the client appeared, etc) on the 0 to 100 severity scale.  They are thanked and leave.  The client now also rates the various items using the 0 to 100 scale.  The final section of the experiment involves looking at the videos of the first and second conversations and repeating the 0 to 100 ratings but this time from the objective record of what the client genuinely looked like.  Note when the client rates how they look on the video, it's important to ask them to do this "As if the person on the video is a stranger ... ".  This is because it seems possible that when the client observes themselves on the video, they may start to feel uncomfortable & self-conscious.  What we need to guard against is the possibilty that they then rate, for example, how anxious they think that they're looking on the video by estimating how anxious they are now feeling looking at the video. The "Assess as if a stranger" instruction is to try to reduce this "cross-contamination".  This is probably the first time the client has ever seen how they actually appear in this kind of social situation with a stranger ... fascinating & potentially very powerful. 

This experience can be hugely important in strongly challenging the client's beliefs that they need to self-focus & use a cluster of safety behaviours in order to come across acceptably in this kind of social interaction.  Very often they will have mind-changing experiences ... for example that they actually appeared more natural, more at ease and socially more competent when they dropped their safety behaviours and focused on spontaneous, open conversation.  They may well, to their surprise, note that they in fact felt more relaxed in the "exposed" second phase of the experiment (with minimised safety behaviours) than in (for them) the more normal, guarded first phase of the experiment.  If they say something like "Surely the main reason I come across better in the second phase of the experiment is simply down to familiarity, a sort of practice effect?"  One can reply something like "I strongly suspect that isn't the main explanation for why the second phase was so improved.  If it was, then a third conversation should be even easier again.  How about we do a third videoed conversation now, but this time reinstate all the self-focus, self-assessment and maximised safety behaviours."  If needed, one then goes through with a third phase of the experiment.  

Note that social anxiety sufferers often carry a negative image/felt sense of themselves that they take into new social interactions and that makes the interactions harder.  It can be helpful to get them to really note how they actually look on the video record and substitute this more accurate, realistic image of themselves for their exaggeratedly negative one when they go into future challenging social situations.  One has probably got to the end of the therapy session by now.  It can be helpful to encourage the client to explore dropping safety behaviours and focusing on conversations (not themselves) over the next days.  Their experience of the videoed experiment can be reviewed again at the next appointment.  Therapy typically then continues with attention training, a series of between-session behavioural experiments and, probably at some stage, then v's now discrimination training & rescripting of early socially traumatic memories.

Treating social anxiety disorder: video (and still) feedback (6th post)

Back last autumn I wrote five detailed blog posts about CBT treatment of social anxiety disorder and also a further post giving access to a series of assessment & monitoring questionnaires - "Self-practice, Self-reflection (SP/SR) & David Clark's treatment for social anxiety: introduction (1st post)""David Clark's treatment for social anxiety: assessment (2nd post)""Treatment for social anxiety: personal aims (3rd post)", "Treatment for social anxiety: avoidance & safety behaviours (4th post)""Treatment for social anxiety: more on avoidance, social skills and compassion (5th post)" and "Assessment & monitoring questionnaires for CBT treatment of social anxiety disorder".  You can get even more on assessment & monitoring by going to this website's "Good knowledge" page - "Social anxiety information & assessment" - and even more on social anxiety generally by retrieving other relevant blog posts through clicking on "Social anxiety" in the tag cloud.

At the workshop I attended with David Clark, he listed "five innovations" involved in his treatment of social anxiety disorder - 1.)  self-focused attention & safety behaviours experiments.  2.)  video (and still) feedback.  3.)  attention training.  4.)  behavioural experiments.  5.)  then v's now discrimination training & rescripting early socially traumatic memories.  He commented that when treating panic disorder one can typically come at it in any old order; the treatment 'wrecking ball' gradually crumbling the construction of unhelpful catastrophic fears.  In contrast, for social anxiety disorder, David feels that the sequence is important with treatment components 1.) & 2.) needing to precede components 3.) & 4.).  The first two components help people to realise that the ways that they have been trying to manage their social anxiety are themselves problematic ... that their attempted solutions are typically aggravating their difficulties.  As a throwaway line, he described social anxiety disorder as involving "a grand opera of safety behaviours".  Treatment components 3.) & 4.) are then only brought in after the initial 'softening up' of unhelpful beliefs achieved by using approaches 1.) & 2.).

In the fourth post in this sequence on social anxiety disorder - "Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: avoidance & safety behaviours" - I discussed identification of safety behaviours in considerable detail.  The subsequent "self-focused attention & safety behaviour experiment" involves in-session increase & decrease of these identified self-defeating coping strategies.  This is very well described in the "Social anxiety" chapter by Gillian Butler & Ann Hackmann in the 2004 book "Oxford guide to behavioural experiments in cognitive therapy".  David showed a series of slides describing this procedure.  He recommended choosing a mid-level social challenge - for example one that is likely to produce approximately 50 units of distress on a simple 0 to 100 scale assessing distress usually caused by a variety of social interactions.  A common example would be a 5 minutes or so conversation with a stooge/stranger (played typically by a colleague or employee of the therapist).  Other options include standing up and giving a short talk, holding a glass of water while chatting, and a variety of other personalised challenges.

The "Safety behaviours video experiment" form (downloadable in Word doc or PDF format) helps therapist & client clarify what safety behaviours are to be emphasised during the experiment and also what is going to be assessed - for example how distressed the client feels during the role play, and also crucially how they feel they "come across".  This might involve assessments of social competence (stupidity, fluency, etc) and/or assessments of anxiety signs (facial colour, sweating, trembling, voice shaking, etc).  It seems important that the client makes explicit demonstrated predictions about just how bad they believe their anxiety signs are going to be, otherwise their biased judgements may just seize on what they see in the video of their subsequent behaviour and say something like "I told you so ... look how badly I come across."  If they have been asked to predict & demonstrate the extent of their observable anxiety before the role play is videoed, then there is a more objective way of demonstrating how their fears have been exaggerated.  So, for example, they could be asked to demonstrate how they feel their trembling or shaky voice or other anxiety signs will actually come across on the video.  For assessment of blushing one can use paint colour charts which can be ordered for free on the internet.  All this allows a more memorable & definite post-experiment checking back on the accuracy of their catastrophic expectations. Remember that a key component of CBT treatment for social anxiety disorder lies in demonstrating that assessing others' judgements from one's own internal anxiety experience is comparing apples with oranges ... others' judgements & one's own inner experience just don't match up particularly closely.  

David also made the puzzling comment that "A big trap is the therapist believing what they see."  I think the point he was making was that the client may well look pretty anxious to the therapist (and to the assistant/stooge as well) when performing the videoed behavioural experiment.  However the client is very likely to estimate that they looked much more anxious than they came across ... so the therapist observes say 30 or 40 degrees of anxiety on a 0 - 100 scale, but the client estimates that they came across at level 70 or 80.  In fact, research suggests that the higher the degree of anxiety, the greater the discrepancy between how someone looks to an outsider and how they feel inside.  So if the therapist sees a fair amount of visible anxiety, it's a good bet that the client is experiencing (and will estimate) a much higher observable anxiety score than the therapist (or stooge) will give them. 

For more on this very interesting use of video experiments in the highly effective CBT treatment of social anxiety disorder, see the next post in this sequence "Treating social anxiety disorder: video (and still) feedback (7th post)".

European positive psychology conference in Amsterdam: what proportion of well-being is genetically determined? (3rd post)

I have already written a couple of blog posts about this 7th European Conference on Positive Psychology - the first on pre-conference workshops about supervision & about relationships and the second on love, national happiness league tables, and life satisfaction assessment. After the coffee break I went on to, what for me turned out to be, one of the most interesting sets of presentations at this conference - an invited symposium on "Biological aspects of wellbeing and resilience".  The key take-home message I left this symposium with is to be much more cautious in how I explain that, when comparing populations, about 36% (a little over a third) of well-being is due to genetic effects, while about 64% (nearly two thirds) is due to individual environmental effects.  For a specific individual however, we're much less clear.  Even if we knew the state of all relevant genes that were involved in affecting the individual's well-being, these effects could still be mostly cancelled out by favourable environmental circumstances (such as loving, responsive parenting).  So many of us should back track on the way we, as professionals interested in well-being, have too easily made comments to people about what percentage of their well-being is genetically and what percentage is environmentally determined.  As these heavy-hitting geneticists highlighted, the research studies coming up with these kinds of percentages are NOT studies on wellbeing in individuals, they are studies comparing different populations.  So when comparing large groups of people we have some justification for saying that about 40% of wellbeing is heritable (36 to 41% in Meike Bartels recent meta-analysis described in this symposium), but this doesn't apply with any great accuracy to a specific individual.  Secondly, even when making this kind of statement about large populations, the percentage of wellbeing attributable to genetic factors tends to decrease in more difficult environmental conditions.  There is increasing evidence for this kind of variation in gene-environment ratio depending on environmental characteristics - see Ragnhild Nes below and also recent research by Bartels & colleagues e.g. this year's paper "Child care, socio-economic status and problem behavior: A study of gene-environment interaction in young Dutch twins" with its conclusion that "heritability is lower in circumstances associated with more problem behaviors" and "the decrease in heritability was explained by a larger influence of the environment, rather than by a decrease in genetic variance."

The "Biological aspects of well-being and resilience" symposium had presentations from five impressive scientists.  Bart Rutten spoke on "Resilience: linking psychological and neuro-biological perspectives".  He mentioned the role of epigenetics, for example effects on methylation produced by early maternal care.  Interestingly, he also referred to using experience sampling via mobile phones to get data that is closer to "real time" than our typical daily, weekly or even less frequent questionnaire methods.  Googling "experience sampling" and "android" or "iphone" highlights the kinds of activity in this area ... one to watch for the future.  Ragnhild Nes spoke about "Causes of individual differences in well-being: an overview of twin and family studies".  My scribbled notes include the following comments: (in large populations, for example of twins) about 30 to 50% of well-being is genetically determined, very little is due to 'shared environment', whereas about 30 to 70% is due to 'unique environment'.  A 2014 meta-analysis of the current research literature gives a figure of about 40% of well-being as heritable, but this percentage decreases in harsher environments.  About 50% of the variance in well-being is stable & this is mostly because of genetic contributions.  About 50% of the variance is variable and this is mostly environmental.  Genetic influences on well-being act primarily via personality, for example neuroticism and extroversion. All personality disorders are associated with decreases in well-being, especially avoidant, borderline & paranoid disorders. 

The third speaker was Meike Bartels, one of those enviable people who look wonderful and whose brains seem razor sharp.  She talked about "Molecular genetics and well-being".  She said that 36 to 41% of well-being is heritable.  In fact the most up-to-date figure from meta-analysis seems to be 36% which pushes the genetic component of well-being down towards only about a third ... quite a decrease from the often quoted 50%.  Like pretty much all the speakers in this symposium though, she underlined that this does NOT explain heritability in a specific individual ... only in comparative studies looking at differences between individuals.  She said that we'll only be able to assess the genetic contribution to well-being for an individual when we know all the relevant genes and, even then, high genetic risk in an specific person might make little difference to their level of well-being because good environment could cancel out the genetic effect.  See the last speaker, Claire Haworth's example of phenylketonuria (below) for more on this point. 

Barbara Fredrickson now spoke on "Gene expression and well-being".  In my experience, Barbara is usually the star of the show when she gives a talk.  She spoke well here, but she isn't a geneticist so it was interesting to see her in the different, heavily statistical environment of this symposium.  Again looking back at scribbled notes, I have written that genomic correlates of loneliness and adversity constitute a "forward-looking immune system" ... isolation & adversity "expect" tissue damage & associated bacterial infection.  She contrasted the "feel-good" quality of hedonic well-being and the "do-good" quality of eudaimonic well-being.  She commented how the two are often reciprocally related with "feel-good" encouraging "do-good" and vice-versa.  She talked about the potential sequence from positive thoughts to positive feelings to positive meaning to healthy genomes.  She mentioned too that eudaimonic well-being seems more strongly related to healthy gene expression than hedonic well-being is.  This reminds me of a series of posts I wrote a while ago beginning with "Purpose in life: reduces dementia risk, increases life expectancy, treats depression and builds wellbeing".

The fifth & final speaker at the symposium was Claire Haworth from the University of Warwick, talking about "Gene by well-being intervention effects".  Again from my notes, I see that she discussed a study done with Sonja Lyubomirsky teaching 47 sets of twins (some monozygotic, some dizygotic, all the same gender) to perform three acts of kindness per day and write a ten minute letter of gratitude (not posted).  These experimental subjects showed increases in well-being.  She commented that baseline levels of kindness had an important impact on response to this intervention with subjects who were already strong in this area benefitting most (another example of the increasingly supported advice that interventions tend to do best if building on strengths rather than trying to correct weaknesses).  She also emphasised that genetic studies are not particularly relevant to well-being in individuals, highlighting that genetic risk is probabilistic not deterministic.  I found it particularly helpful when she illustrated this point with the example of phenylketonuria (PKU).  As Wikipedia comments "This genetic disorder is characterised by the inability to metabolise the amino acid phenylalanine."  It was only identified in 1934.  Untreated it leads to "intellectual disability, seizures, and other serious medical problems.  The mainstream treatment for classic PKU patients is a strict PHE-restricted diet supplemented by a medical formula containing amino acids and other nutrients ... Patients who are diagnosed early and maintain a strict diet can have a normal life span and normal mental development."  What a nice example ... a genetic life-destroying sentence beautifully reversed by an appropriate, skilful environmental response.  Absolutely, for a given individual, genetic risk is probabilistic not deterministic.  Great stuff ... and a great symposium!

For the next post in this sequence about the European Positive Psychology Conference in Amsterdam, click on "Self-determination theory, positive aging, and the economic crisis." 

European positive psychology conference: love, national happiness comparison tables, & life satisfaction assessment (2nd post)

I wrote yesterday about the two pre-European Conference on Positive Psychology (ECPP) workshops I went to on "Positive supervision" and on "Positive relationships".  Then in mid-afternoon on Tuesday, the conference proper began.  It was heralded by Taiko drummers and a cluster of brief welcoming speeches.  Apparently there are 920 people at the conference from about 50 different countries.  The country spread is similar, but the numbers are up 50% on the approximately 600 attendees at the 5th ECPP I went to in Copenhagen four years ago.  We now have three days of conference with 10 invited symposia, 5 invited workshops, 29 symposia, 29 workshops, 34 thematic paper sessions, and 214 posters.  It's going to be a bit of a journey!

And the journey started with a bang - the admirable Barbara Fredrickson giving a keynote presentation entitled "Love and health".  I am (probably like the vast majority of people with a scientific interest in positive psychology) a big fan of Barbara Fredrickson's.  I hadn't bought her new book "Love 2.0", but I have ordered it now.  I took pretty extensive notes during this talk, including fascinating information about an as yet unpublished research study contrasting groups randomized to train in mindfulness or to train in a loving kindness meditation (the latter appears to boost positive emotions more and this has knock-on benefits for physical health via inflammatory & immune changes).  I'll write more about Barbara's keynote once I'm home again after the conference and I've had a chance to look at her new book as well.

The next day began with keynotes by the conference chair, Jan Walburg, on "The promise of positive psychology for society" and John Helliwell from the University of British Columbia on the "World happiness report".  John Helliwell is a professor of economics and a former president of the Canadian Economics Association.  He also seems brilliant, a thoroughly nice guy, and one of the absolute world experts on happiness & wellbeing at countrywide levels.  Once he'd finished, I walked up to the front of the lecture hall to thank him for his deeply fascinating talk.

Wikipedia states "The World Happiness Report is an annual measure of happiness published by the United Nations Sustainable Development Solutions Network.  In July 2011, the UN General Assembly passed a historic resolution inviting member countries to measure the happiness of their people and to use this to help guide their public policies   The first World Happiness Report was released in 2012 ... it drew international attention as a landmark first survey of the state of global happiness ... the report is edited by Professor John F. Helliwell ... Lord Richard Layard ... and Professor Jeffrey D. Sachs ... ".  John, in his talk, described findings from the most recent survey published in 2013.  The 155 page report is freely downloadable from the internet.  Its eight sections include "World happiness: trends, explanations and distribution", "Mental illness and unhappiness" (mental illness is the single most important cause of unhappiness, disability & absenteeism worldwide but it is largely ignored by policy makers), "The objective benefits of subjective well-being" and "Using well-being as a guide to policy".  Six factors explain three quarters of the variation in happiness scores over time and among the 150 or so countries involved.  These six factors are GDP per capita, healthy life expectancy, having someone to count on, perceived freedom to make life choices, freedom from corruption, and generosity.  Fascinating stuff and well worth digging into more in the future.

We now had a somewhat overwhelming choice of 16 different workshops, symposia and presentations of papers.  I went to symposium on "Positive psychological assessment".  The main take home message I noticed here was from a talk by Charlie Lea on "Happy thoughts: high life satisfaction and the use of the best supporting life domains".  She seemed to replicate a finding that she said had also been noted by Ed Diener.  When assessing life satisfaction, one can do this "globally" (for one's life in general) or one can do it bit by bit for the various aspects/domains of one's life.  Apparently those who report higher global life satisfaction scores not only have higher average scores across their different life domains (than those reporting lower global satisfaction), but also seem to be more influenced in their overall global scores by the domains where they score particularly highly (glass half full).  Those reporting lower overall global scores lose twice - both in having lower average scores across their life domains, and also in being more influenced in their global assessments by domains where they score poorly (glass half empty).  Mm ... there could well be useful clinical/real life interventions here seeing if one can help people with low global assessments to "count their blessings", notice what is going well for them, and possibly use gratitude interventions to underline these positive areas.  A research study in the making!?       

See tomorrow's post for what happened "after the coffee break"!   

European positive psychology conference in Amsterdam: workshops on supervision and on relationships (1st post)

The 7th biennial European Conference on Positive Psychology (ECPP) began here in Amsterdam yesterday.  Four years ago, I went to the 5th European Conference in Copenhagen.  It was pretty special and I wrote extensively about it in this blog - see, for example "European positive psychology conference in Copenhagen: arriving, opening speeches & reception".  

As so often happens with big conferences, there were a number of initial pre-conference workshops available.  I went to a couple of three hour events - Fredrike Bannink on "Positive supervision" and Sue Roffey on "Positive relationships".  Fredrike's workshop was fast-paced, highly experiential, great fun and, for me, dramatically lacking in any serious attempt to back up her claims with any hard data. It reminded me of the old chestnut “It’s important to keep an open mind, but not so open that your brains fall out.”   As far as I could pick up, the only research study she mentioned to support the workshop’s relentless focus on building on successes rather than problem-solving failures was a 2009 study by Histed et al – "Learning substrates in the primate prefrontal cortex and striatum: sustained activity related to successful actions" – interesting but surely not an adequate justification for a whole workshop.

I don't want to be too mean here.  I think Fredrike is an inspiring presenter - warm, brave, caring, fun.  In some ways though, this makes the workshop even more "dangerous".  Supervision as an exercise is not well supported by extensive research data.  It's quite a strong statement to argue additionally that we should be trying "positive supervision" characterised by focusing on what our supervisees seem to be doing well in their work rather than exploring where they seem to be stuck.  Fine to make strong statements, but surely the next step is to try to see whether our hypothesis is or is not supported by results?  Let's not argue from learning data in primates when there is actually much better evidence available - see, for example, the three posts on this blog beginning with "New research suggests CBT depression treatment is more effective if we focus on strengths rather than weaknesses".  But if one was going to try to build "positive supervision" from this "positive psychotherapy" foundation, then I wouldn't have run the workshop in this way.  Fredrike also introduced the potential use of feedback from our supervisees elicited using the "Session rating scale" (SRS).  Mm ... this scale quite specifically asks about "failures" (where things went wrong, not where they went right) and actually the SRS and related ORS scales are being used for very interesting innovations in supervision, but not in the way that Fredrike suggests.  Scott Miller very carefully sifts supervisees' results to look for and learn from failures, not successes.  If you'd like to know more, follow some of the links in the post "Client-directed, outcome-informed therapy: a workshop with Scott Miller".  So for me this initial workshop was lots of fun, but not really a good use of time.

I then went on to three hours or so on "Positive relationships" with Sue Roffey.  Sue is the editor of a recent, interesting, multi-authored book "Positive relationships: evidence based practice across the world" and she stated that the workshop would be based on "commonalities across 17 chapters - connection, ecology, constructing culture, strengths and solutions, emotional and social literacy and learning, and social capital".  This workshop seemed to be a better mix of experiential exercises, research data, theory and explanation.  It was a bit school-focused rather than therapy-focused for me, but education is Sue's world and the work she knows.  What did I take away?  Well there were some fun tips for running workshops.  One was the way she provided fairly large sticky address labels and marker pens at the start.  She asked us all to write our first name on a label and then stick it on ourselves so other could it easily.  At one stage, later on, she also introduced a delightful "laughing together" exercise involving saying "toothlessly" to the next person in the circle "Have you seen Mrs Mumbles?".  The next person then replies "toothlessly" "No I haven't but I'll ask my neighbour" ... and so on round the group (possibly in both directions).  Nice ... light-hearted ...

What about the more academically "chewy" stuff?  Sue talked a good deal about raising kids.  She spoke about parenting styles - specifically facilitative/authoritative rather than authoritarian, indulgent or neglectful.  She showed us a recently produced one minute video called "Children see Children do" .  It's special and made me cry (and still does!) ... do watch it here on YouTube.  Sue spoke about her moving work with the "Aboriginal girls circle", triggered me to look again at Wilkinson & Pickett's fine book "The spirit level: why equality is better for everyone", mentioned Putnam's "bonding and bridging social capital" (I like the "150 things you can do to build social capital" listed on the Putnam-linked website "Better together"), appreciated Shelly Gable's work on active, constructive responding (see, for example, Gable's classic paper "Will you be there for me when things go right?"), and introduced ideas from John Gottman's work on marriage ... to mention just some of the areas we touched on.  Good stuff ... and I loved being reminded of the Margaret Mead quote - "Never doubt that a small group of thoughtful, committed citizens can change the world; indeed it's the only thing that ever has."  Wonderful!

In tomorrow's post I describe the start of the conference proper. 

Five 'prescriptions' for flourishing more fully

(this blog post is downloadable as a handout both in Word doc and in PDF format)

Professor Ken Sheldon is a bit of a hero of mine.  I've followed his research for many years and have great respect for his work and what I've gleaned about the way he leads his life.  I have just been looking at the recording of a lecture he gave at the University of Missouri a little while ago. The points he makes about how to flourish more fully are still pretty much bang on.

To find out more about his work, you can visit his website.  There he provides PDF's of some of his ground-breaking research publications.  This list could do with updating though.  Some of his most intriguing papers have been co-authored with Sonja Lyubomirsky and her site provides further recent PDF's of their shared and other related research studies ... including the excellent "Becoming happier takes both a will and a proper way" and "The challenge of staying happier".  Ken has also written a series of fascinating books.  Examples are the recent "Self-determination theory in the clinic: Motivating physical & mental health" and "Positive motivation: a six week course" as well as the ambitious "Optimal human being"

In his lecture "Pursuing happiness: What works and why", he gives five "happiness prescriptions".  They're well worth noting and it would make excellent sense to check out how fully we're following these suggestions in our own lives.  Here they are:

  • Focus more on changing what we do, rather than on what we have.  Then vary what we do (guard against getting into ruts). Humans quickly habituate/get used to new situations.  There are evolutionary survival advantages to this process but it drives hedonic adaptation -  a process where despite improvements in our circumstances (new job, bigger car, welcomed relationship, etc), we tend to return fairly soon to a largely genetically determined happiness set point (or set range).  However we adapt less to new activities than we do to new acquisitions.  Most of us know this, but we still tend to underestimate how much fresh activities can benefit us more than new possessions
  • Pursue intrinsic goals for self-concordant reasons - out of interest, not pressure; expressing identity, not reducing guilt.  A blog post I wrote a while ago about "Self-determination theory" gives more details about how the kinds of goals we choose (intrinsic or extrinsic) and the motivations behind our choices (autonomous or controlled) have major impacts on how fulfilled we become.
  • Try more often to be your unguarded self in social situations.  The unguarded self is a way of describing how we are when we're with those we know and love.  The social self describes how we tend to act in less familiar social situations.  People have higher wellbeing when they are more often able to be their authentic unguarded self (both through their behaviours and through the relationships & environments they have developed in their lives) - see, for example, Ken's paper "What does it mean to be in touch with oneself?" for more on this.
  • Balance your time across your day.  To flourish more fully, research suggests we should honour our needs for autonomy, competence and relatedness.  Satisfying say a couple of these needs does not adequately make up for ignoring the third.  The paper "The balanced measure of psychological needs (BMPN) scale" explains this more fully and you can check on how you're doing by filling in the BMPN questionnaire.
  • Try to manage your life so that you feel autonomous, competent and connected.  These central psychological wellbeing needs - basic nutrients for happiness & flourishing - are illustrated in the handouts on "Psychological needs & wellbeing" further down this website's "Good knowledge" page on "Self-determination theory".  And for a true wealth of further information go to the major "Self-determination theory" website.


These really are a wise set of suggestions to pay attention to.  Good luck in your own exploration of "flourishing".

The importance of 'emotional' not just 'rational' empathy

I'm just back from four days away with friends down in Cumbria.  I have been going to these long residential Spring weekends on the edge of the Lake District for well over twenty years and have written a lot about them too ... see for example the sequence of posts from a couple of years' ago beginning "Peer groups, Cumbria spring group: first morning - arriving".

There are so many reasons why I go to these groups ... friendship, a wonderful chance for a break in beautiful countryside, 'retreat', fun, psychological exploration, so much.  And one reason is definitely about 'emotional yoga'.  I use this phrase because it describes so well some of what I gain from these interpersonal groups.  I do 'physical yoga' partly to keep supple & strong.  I know my body is stiffening up as I age. Typically three times a week, I take a bit of time to do a series of stretches.  I started this process back in the late 1960's.  I hope I'll keep doing the stretches right up to the end of my life.  I don't expect to stop and, if I did, I'm confident that I would stiffen up more quickly than I already do.  

There's a parallel with my intra- and inter-personal flexibility.  If I don't 'practise' regularly, if I don't stretch & challenge myself in the sensitivity & depth of my relationship with myself & others, I feel I tend to 'stiffen up'.  And that's what the data shows ... see the recent study "Empathic concern and perspective taking: linear and quadratic effects of age across the adult life span" ... with its finding that both 'perspective taking' and 'empathic concern' seem to improve initially as we age, but then as we get still older these crucial interpersonal qualities begin to deteriorate. There's a parallel too with this year's paper "Wisdom and mental health across the life span" with the suggestion that older people tend to lose wisdom as their openness deteriorates.  In a way, these groups I take part in are practice at deep relationship, at intimacy, at going down again into that 'mindfulness practice' ... "What do I really feel right now?" ... and going down again into that related 'mindfulness practice' ... "What is happening for this other person right now?  How are they feeling?"  The blog post "Meeting at relational depth: a model" provides a map of this territory and last year's paper "Constructs of social and emotional effectiveness: Different labels, same content?" highlights that 'Expressivity' and 'Sensitivity' seem key components of intra- and inter-personal competence.

Over the years, I have written a good deal about empathy on this blog.  Of central interest seems to be the distinction between 'rational' empathy and 'emotional' empathy.  So in the blog post "Do psychotherapists, doctors and leaders develop "emotional chainmail? Two kinds of empathy", I wrote: Emotional and physical pain is all mixed up in a bundle often affecting the same nerve tissue - see, for example "The neural bases of social pain: Evidence for shared representations with physical pain."  And when we empathise with another's pain, we actually feel it; it may well literally hurt us too - see "Meta-analytic evidence for common and distinct neural networks associated with directly experienced pain and empathy for pain."  This is true for physical pain and it is also true for emotional pain.  As authors Singer & Lamm write in their paper "The social neuroscience of empathy" - "Consistent evidence shows that sharing the emotions of others is associated with activation in neural structures that are also active during the first-hand experience of that emotion."  And they go on to say " ... recent studies also show that empathy is a highly flexible phenomenon, and that vicarious responses are malleable with respect to a number of factors — such as contextual appraisal, the interpersonal relationship between empathizer and other, or the perspective adopted during observation of the other."  It seems useful to distinguish cognitive empathy (mentally understanding what the other person is experiencing) and emotional empathy (actually sharing what they're feeling).  This is well described in Walter's paper "Social cognitive neuroscience of empathy: Concepts, circuits, and genes".  We are more likely to feel emotional empathy when we have a sense that the other person is similar to us (see Preis & Kroener-Herwig's 2012 paper), so Meyer et al showed in their research - "Empathy for the social suffering of friends and strangers recruits distinct patterns of brain activation" - that observing a friend's (social) suffering "activated affective pain regions associated with the direct (i.e. firsthand) experience of exclusion ... and this activation correlated with self-reported self-other overlap with the friend. Alternatively, observing a stranger's exclusion activated regions associated with thinking about the traits, mental states and intentions of others ['mentalizing']."  At worst, cognitive empathy involving only perspective taking (in contrast to the shared feelings of emotional empathy) can be used to help "read" another's mind and manipulate them for personal gain - see "Why it pays to get inside the head of your opponent: The differential effects of perspective taking and empathy in negotiations".

Empathy - probably particularly emotional empathy - is of very considerable importance for psychotherapists (Elliott et al, 2011), for doctors (Mercer et al, 2012) and for close relationships more generally (Canevello et al, 2011 & Sullivan et al, 2010).  Worryingly there is research suggesting that empathy actually declines over the course of medical training (Neumann et al, 2011) and may be declining as well in the general population (Konrath et al, 2011).  In tomorrow's blog post (the third & last in this sequence on "emotional chainmail") I'll look at ways that can help us "get the best of both worlds" - maintaining emotional stability while also staying empathically & emotionally connected with others.

More to follow ...