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

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

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

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

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

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

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

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

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

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

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

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

 

Birmingham BABCP conference: second day - NICE, emotion regulation, and exposure with depression & with cycloserine (4th post)

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.

Time for the last morning of the conference ... see the post "Final morning - positive affect in depression, therapy adverse effects & overall review (5th post)".  

Birmingham BABCP conference: first day - decentering, compassion, insomnia, social anxiety, sp/sr & barbecue (3rd post)

This is a quick overview of the first full day of the annual BABCP summer conference in Birmingham.  I intend to return to some of the key learning points in later posts.  I've already written about the pre-conference workshop I went to on "Emotion regulation" in a couple of earlier posts. Apparently the conference itself offers 37 symposia, 5 panel discussions, 3 clinical roundtables, multiple poster sessions, 13 skills classes, numerous special interest group & branch meetings, and 18 keynote addresses - all over the course of two and a half days here on the University of Birmingham campus.  The freely downloadable 101 page abstracts book gives a great sense of what's on offer.

It regularly strikes me - when attending these big multi-track conferences - that it would be very possible to come with several colleagues and all end up going to totally different sets of presentations.  The conference is a buffet of choices and part of the challenge is to construct a personal "academic meal" that will really feed our own particular work & intellectual needs.  So yesterday the "meal" I put together involved dipping into a symposium on "Elucidating the mechanisms & moderators of meditation enriched treatments: At the confluence of CBT, affective science, and contemplative practice" before switching across to another on "The role of compassion in mental health".  I then went to a fine end-of-morning keynote on "The past, present and future of psychological therapy for insomnia disorder", glanced around some poster presentations, had lunch and went on to a great skills class on "Optimising video feedback for social anxiety disorder: Face-to-face and virtual techniques".  Finally I attended a keynote on "Why CBT therapists need to take a good look at themselves", briefly checked out the posters again, before chilling out and then wandering along to the conference barbecue.  Full day! 

So first, dipping into the symposium on "Elucidating the mechanisms & moderators of meditation enriched treatments".  I was interested to hear David Fresco - co-presenter at the pre-conference workshop I went to on "Emotional regulation" - talk about "Decentering from distress: Regulating negative emotion by increasing psychological distance."  His abstract states: "Decentering, which represents one’s ability to observe thoughts and feelings as temporary, objective events in the mind, as opposed to reflections of the self that are necessarily true, is present-focused and involves taking a nonjudgmental and accepting stance regarding thoughts and feelings. Although the concept of decentering can be found in traditional cognitive therapy (e.g., Beck et al., 1979), Teasdale and colleagues (2002, p. 276) suggest that it was primarily seen as “a means to the end of changing thought content rather than, as ... the primary mechanism of therapeutic change.” Increasingly, evidence has validated decentering as a construct important in the acute and enduring treatment of MDD and anxious depression (Fresco, Segal et al., 2007; Mennin & Fresco, 2011), GAD (Hoge, Bui, Goetter, Robinaugh, Ojserskis, Fresco, & Simon, 2013) and in the prevention of MDD relapse following prophylactic treatment with mindfulness based cognitive therapy (MBCT; Bieling et al., 2012). Given these promising findings, research has increasingly sought to elucidate the biobehavioral markers of decentering associated with its salutary benefits. In particular, this work has initially focused on decentering’s relationship to negative self-referential processing (Barron et al., 2013; Mennin & Fresco, 2013; Vago & Silbersweig, 2012). A recent study with fMRI assessment and neural correlates of treatment following MBCT revealed that decreased activation in the posterior cingulate cortex (PCC), a region associated with experiential and nonjudgmental self-reflection (Johnson et al., 2006) was associated with high self-report decentering and low relapse (Fresco, Shepherd, Farb, & Segal, 2013). Thus, despite these promising findings, study of decentering has largely been limited to self-report, and the mechanisms through which decentering alleviates and prevents the symptoms of depression remain unexplored.  As a first step to address this gap, we developed and began validating two objective decentering tasks of individuals’ ability to create psychological distance (i.e., decenter) in response to negative emotional provocation. Tasks manipulated psychological distance either implicitly or explicitly, and self-reported negative affect and arousal were collected as a function of increasing distance from distressing visual stimuli (e.g. images of poisonous insects or snakes). We examined associations between task performance, in terms of reductions in distress from distancing, and self-report measures of depressive and anxiety symptoms, trait mindfulness, and emotion regulation.  We found that implicitly increasing psychological distance from distressing visual stimuli reduced emotional reactivity to those images, but only in individuals with low levels of self-report depression (ηp2 = .08) and emotional avoidance (ηp2 = .05), and high levels of mindful awareness (ηp2 = .1). Explicitly increasing distance was associated with reduced emotional reactivity in individuals scoring high on cognitive reappraisal (ηp2 = .1). Our data suggest that the capacity to increase psychological distance in response to negative emotional provocation may depend on 1) depressive symptomology and trait emotion regulation styles, and 2) level of awareness (implicit vs. explicit).  Additional experimental and neurobiological studies of decentering may enhance our understanding of its underlying mechanisms while informing clinical efforts to promote decentering in a therapeutic context."  OK, I want to make a fairly quick pass across the various presentations I attended today.  I intend to come back to pull out the "therapeutic cherries" in later posts.

So I now upped and headed across to the symposium on "The role of compassion in mental health".  I caught the tail end of Caroline Falconer's presentation on using virtual reality technology for encouraging self-compassion.  I particularly wanted to hear the fine Willem Kuyken on "Does self-compassion attenuate reactivity in people at risk from depression?"  Sadly Willem hadn't been able to get to the conference, so the talk was given by his colleague & fellow researcher Anke Karl.  The abstract read: "Self-compassion may enable people at risk for depression to break the link between cognitive reactivity and a spiral of negative mood and thinking that can trigger depression (Kuyken et al., 2010). This experimental study showed that following a sad mood induction people at risk for depression able to deploy self-compassion are better able to repair sad mood. This has implications for how to build resilience in people at risk for depressive relapse."  Interestingly I can see from the abstracts book that the initial talk by another of Willem's colleagues Hans Kirschner might have been more practically useful with its comment that "We ... studied psychophysiological correlates of two meditation exercises (Loving Kindness Meditation and Compassionate Body Scan) designed to cultivate state self-compassion ... Further explorations of these findings suggested that responses to the self-compassion conditions were moderated by participants' tendencies to self-criticize. Individuals high in self-criticism tended to respond to the compassionate body scan (i.e., a more indirect approach to cultivate self-compassion) with higher activation of the positive affiliative affect system but not to the loving kindness meditation (i.e., a more direct approach to cultivate self-compassion), while those participants low in self-criticism showed the opposite pattern. This indicates that both forms of meditation can have beneficial effect on the positive affiliative affect system and point towards differential indications for offering them to individuals based on their tendencies to self-criticize."  This looks worth following up.  Then Paul Gilbert gave a conceptual talk on "What is compassion?" highlighting how much variety there is in what people have meant by this word.  In many ways this variety provides a welcome richness, but it's tricky when trying to do research in this area.

After coffee, Colin Espie gave an end-of-morning keynote on "The past, present and future of psychological therapy for insomnia disorder."  I have been to a day workshop on insomnia with Colin in the past.  What a wonderfully knowledgeable man he is in this whole area.  The abstract of his talk read: "Insomnia Disorder is extremely common and represents a risk factor for subsequent mental and physical health problems, yet it is poorly managed in practice. CBT has the strongest evidence base for treating persistent insomnia, but historically it has proven difficult to make it available. Digital (web and mobile) therapy offers a personalised behavioural medicine solution, that could stand alone or integrate with face to face therapy. This presentation will summarise the evidence base for various CBT delivery methods and propose a way forward for delivering effective care at population level."  It is interesting how a cluster of experts are pushing forward with web-based, often therapist-supported, delivery of carefully thought through, evidence-based treatment packages.  Colin's www.sleepio.com is just such an initiative ... excellent and, as a therapist, one can dovetail with this service, monitoring how one's clients are doing with the sleepio insomnia programme as well as receiving useful research updates and the opportunity to discuss relevant issues with colleagues.  

Then lunch and to a great skills class with Jennifer Wild on "Optimising video feedback for social anxiety disorder: Face-to-face and virtual techniques".  I have written extensively on this blog about use of video with social anxiety disorder ... see, for example, "Treating social anxiety disorder: video (and still) feedback".  It's wonderful though to get a chance to pick up tips from a hugely experienced expert in a particular area. Brilliant ... this single skills class was, for me, worth a good half of the full conference fee.  Happily I got a chance, standing in the queue for food at the barbecue in the evening, to say to Jennifer how much I appreciated what she shared with us.  I'll write a whole blog post about the skills class later.  Then finally an end of day keynote with my friend, James Bennett-Levy on "Why CBT therapists need to take a good look at themselves". James is having a busy conference giving a pre-conference workshop, a symposium and now this major lecture ... exhausting!  The abstract reads "This keynote will address questions such as: How do therapists develop therapy skills? What makes us good or poor therapists? What is reflective practice? What do we mean by ‘self-reflection'? What is the value of personal development in therapist training? Do we all need personal therapy, or are there other options?  Drawing on the Declarative Procedural-Reflective (DPR) model of therapist skill development (Bennett- Levy, 2006, Bennett-Levy & Thwaites, 2007; Bennett-Levy et al., 2009)) and research and writing across a number of countries (e.g. UK, Ireland, Germany, Australia, New Zealand, Austria, USA) over the past 15 years, James will argue that self-reflection and self-practice of therapy skills are central to the development of therapist competence and expertise in CBT. The talk will discuss current understandings of reflection, and examine the empirical evidence for the value of self-practice and self-reflection (SP/SR) in therapist training. It will conclude with some ideas about how, as CBT therapists, we can best ‘take a good look at ourselves' to enhance our professional, and personal, development".  Apparently the full lecture should be available on James's website.  

A very good full day.  I plan to revisit some of the main points in future blogs, but right now ... off to the second day of the conference's presentations ... and click here for a report on how the second day went.

Birmingham BABCP conference: pre-conference workshop on emotion regulation therapy with Doug Mennin & David Fresco (2nd post)

Yesterday morning I wrote about the BABCP pre-conference workshop that I was going to on "Emotion regulation therapy".  I cut & pasted information from the workshop publicity into the blog and many further details about this approach are available from their website "Emotion regulation therapy for chronic anxiety and recurring depression".

So how was the workshop?  Well, I'll give a narrow focus set of comments first, then I'll try to put this into the broader context of whether this new emotion regulation approach is likely to add to our helpfulness as therapists who struggle to relieve suffering more effectively.  So the narrow set of comments first ... well I think Doug & David did a bloody good job.  Wow, what a huge amount of work is involved over many years when one seriously tries to develop a more effective treatment approach.  They have gone about this persistently, thoughtfully, openly.  Great.  Huge congratulations to them.  

The early treatment outcomes are encouraging as well.  Quoting from their 2013 paper "Emotion regulation therapy for generalized anxiety disorder": "To date, the efficacy of ERT has been demonstrated in a recently concluded NIMH-funded open trial (OT; N = 19) and a randomized clinical trial (RCT; N = 60; Mennin & Fresco, 2011; Mennin, Fresco, Heimberg, & Ciesla, 2012) ... In terms of clinical outcomes, OT patients evidenced reductions in both clinician-assessed and self-report measures of GAD severity, worry, trait anxious, and depression symptoms and corresponding improvements in quality of life with within-subject effect sizes well exceeding conventions for large effects (Cohens ds = 1.5 to 4.5). These gains were maintained for 9 months following the end of treatment. The RCT patients receiving immediate ERT, as compared to a modified attention control condition, evidenced significantly greater reductions in GAD severity, worry, trait anxious, and depression symptoms and corresponding improvements in functionality and quality of life with between-subject effect sizes in the medium to large range (d = .50 to 2.0). These gains were maintained for 9 months following the end of treatment ... not surprisingly given comorbidity rates (Kessler, Berglund, et al., 2005; Kessler, Chiu, Demler, & Walters, 2005), a sizable subgroup of GAD patients with comorbid MDD (N = 30) were enrolled and treated. Within-subject effect sizes in both clinician-assessed and self-report measures of GAD severity, worry, trait anxious, and depression symptoms and corresponding improvements in functionality and quality of life were comparable to the overall trial findingsthereby suggesting that MDD comorbidity did not interfere with treatment efficacy (Cohens ds = 1.5 to 4.0)."  OK.  So far, so good.  There's a long way to go before I would firmly support this approach as a significant step forward for treatment of challenging clients presenting with GAD and comorbid problems with depression.  The literature is kind of littered with painstakingly developed, fairly complex therapies attempting ... and failing ... to produce better results for GAD than simple well-taught applied relaxation.  Fingers crossed for ERT.

 

General point ... see the major 2nd edition upgrade of this year's 668 page "Handbook of emotion regulation" edited by James Gross & involving contributions by over eighty other researchers.  

More to follow ... 

Birmingham BABCP conference: pre-conference workshop on emotion 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 and 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 for - "Emotion regulation therapy" with Doug Mennin from the City University, New York and David Fresco from Kent State University, Ohio.  Their website "Emotion regulation therapy for chronic anxiety and recurring depression" gives a wealth of material about this approach.  Today's 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. 

Gosh that's plenty of information ... maybe a bit too much.  So how did the workshop actually go? ... see tomorrow's post "Pre-conference workshop on emotion regulation therapy with Doug Mennin & David Fresco (2nd post)"

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."