Yesterday I wrote about the "Discussion on the Dodo assertion - all good depression treatments are equally effective."  What happened next? It was keynote lecture time ... with a choice of four. Probably I should have cold-bloodedly chosen to go back to Don Baucom on "Relationship functioning and adult psychopathology: couple-based interventions to treat individual disorders" as couple therapy is a major theme for me this conference. Certainly the abstract highlighted its interest for me: "Because adult psychopathology has traditionally been viewed as individual disorders, interventions have typically emphasized individual psychotherapy. However, these problems exist in an interpersonal context, and intimate relationships can either exacerbate or help to alleviate individual distress. In the current presentation, Professor Baucom will first review what is known about associations between relationships and individual functioning. Next, he will present an overview of models for treating individual psychopathology from a couple-based perspective, along with current empirical findings frothe field across disorders. Finally, he will present results from two of his current treatment studies which are in progress, providing couple-based interventions for anorexia nervosa and obsessive-compulsive disorder". Actually I would also have loved to hear the illustrious Constance Hammen talk on "The social context of adolescent depression: vulnerability and consequences." Damn ... you wait an age for a bus going in an interesting direction and then several come along all at once!

OK, but these conferences throw up this kind of decision challenge. I plumped for a presentation instead by the very impressive Susan Bogels. She spoke on "The role of the father in the etiology, prevention and treatment of childhood anxiety disorders." The talk's abstract read "Children are born with fears that protect them against danger. Yet instinctive fears may undermine confidence and learning. Confronted with novel and potentially dangerous stimuli, newborns rely on their parents for clues as to whether the situation is an opportunity or danger, and thus should be approached or avoided. If parents are fearful themselves, they will show signals that may enhance child fear. From an evolutionary perspective, fathers have specialized in external environments (confronting dangerous animals, fighting strangers, exploring new territory) while mothers specialized in the internal environment (feeding and comforting the child). Given this evolutionary-based comparative advantage of fathers, two predictions can be made: First, fathers may play a different (but important) role in child upbringing, such as stimulating risk taking and competition. Second, infants may overvalue the signal of their father compared to their mother to decide whether the external environment represents threat or opportunity. In this keynote, first an overview will be given of the role of evolution in parenting. Available research on differences in paternal and maternal parenting behaviours will then be reviewed, in the context of child anxiety and avoidance and its opposite; confidence and risk taking. Next, research from our lab will be presented on the different roles of father and mother in preventing child anxiety, based on our longitudinal study of 140 first-born babies in interaction with both their father and their mother. Video-examples of typical father and mother behaviours in interaction with their child will be given to illustrate differences. Also, clinical research will be presented on fathers versus mothers as coaches of their child to help the child overcome anxiety disorders. Finally, the scientific, clinical and societal implications of this paternal model will be discussed." Lovely stuff. Susan Bogels is certainly a bit of a star. Great to dip into a field that interests me but that I know little about.

The afternoon was more curtailed for me. Having wanted to go to three out of the four morning keynotes, I didn't particularly fancy any of the late afternoon's. They all looked of some interest but not enough to pull me in. I did however (continuing my focus on couple work) get to the early afternoon symposium - one of eighteen choices - on "The role of the individual in relationship distress and interventions". This included four presentations. The first was "The PREP program for individuals and couples: can interventions with one spouse help the relationship?" Interesting. The abstract commented "A major issue in the couples' intervention field is whether couples can benefit when only one partner receives the intervention. The prevailing belief based on early studies (e.g., Gurman & Kniskern 1997) is that individual interventions not only do not work, but they often do harm to the relationship (Gurman & Kniskern, 1977). Here we present a study designed to test in a randomized clinical trial if a version of the PREP (Prevention and Relationship Education Program) delivered to men and woman separately would have positive spill over to the marital relationship. Results to date indicate that when only one person attends the intervention, the other partner and the relationship improves. This suggests that when therapists can effectively work with only one partner "in the room" if they have a couples perspective as they conduct couples therapy. Implications for service delivery on a nationwide scale and for clinical practice are discussed." This looks like an important finding. Its hard to get couples to come to therapy or to groups (although "selling" it as "enriching" how well things are going rather than "treating" how badly they're going may make interventions less threatening). Women are typically much more ready to come than men. No surprises here - it reminds me of the joke "Question: What are the scariest six words a man can hear from his partner? Answer: Let's talk about our relationship!" Women are typically much more ready to come to a group on enriching marriage. The really encouraging finding is that such attendance may well be associated with as good or better couples outcomes as getting the full couple to come along. An intervention that's easier to arrange and that gets as good or better outcomes. We can't lose!

The second presentation was on "Helping couples confronting a major life challenge". The paper commented on " ... the results of three randomized controlled trials of couple based programs, one focused on couples in which the woman has breast cancer, one on couples in which the man has prostate cancer, and one in which the couple are making the transition to parenthood. A common theme across the studies is that couple based treatments that promote dyadic coping and develop effective mutual support can enhance individual and relationship functioning." Good, helpful, encouraging ... would that such interventions were more routinely available. Hospital clinicians please note the value of integrating this kind of work into specialist clinics for cancer, obstetrics and, probably, many other disciplines. The third presentation was on "Marital discord and depression in a community-based sample of couples seeking treatment." This replicated the well-known finding that depression and couple discord commonly co-occur. There was an interesting comment that, on the whole, for women there is a stronger link from marital discord to subsequent depression, while for men the reverse pathway is stronger from depression to marital discord. The caution that emerged from this paper was that - although marital therapy is recommended as an evidence-based intervention for depression with co-occuring marital difficulties - in community samples the outcomes for marital therapy are significantly worse when depressive symptoms reach criteria for clinical depression. Maybe the solution is to incorporate expertise on depression treatment alongside expertise at couple therapy. Oh dear, good couple therapists and good depression therapists are both too rare. A therapist who is experienced and good with both modalities is rarer still. The last presentation was "Side-by-side: a couples-based skills intervention for breast and gynaecological cancer patients." As in the second presentation of this symposium, this kind of couple focus yielded clearly better results for both the couple and for the woman herself. I ache a bit knowing this kind of help is very much the exception rather than the rule. If you're interested in the way forward for couple therapy, a good source to visit is the recent book "The shape of couple therapy to come: enhancing couples" edited by Hahlweg, Grawe-Gerber and Don Baucom.

See tomorrow's post for "Last morning and reflection".