KEYNOTE SPEAKERS

David Clark

Cognitive Therapy for Anxiety Disorders: From Science to Practice

David M Clark,
Institute of Psychiatry, Kings College London, UK

The development of cognitive therapy for anxiety disorders has been based on an unusually close interplay between experimental studies that aim to identify maintaining factors in the various disorders and treatment development work that focuses on changing these maintaining factors. This interplay is illustrated in the first part of the talk, after which several key questions about cognitive therapy are addressed. These include: How effective are current cognitive therapy programmes for different anxiety disorders? Do the results of clinical trials generalise to less selected clinical populations? To what extent are maintaining factors disorder-specific or trans-diagnostic? What are the mechanisms of change in cognitive therapy? How can we best train therapists to be effective cognitive therapists? Is the traditional one session a week for  2-4 months format the best way of delivering cognitive therapy or can it be concentrated into a much shorter period of time without loss of effect?

Christopher Martell

Twenty Years of Behavior Therapy: Trends and Counter Trends

Christopher Martell,
University of Washington, USA

Behaviour Therapy underwent remarkable change from the 1950s through the 1980s.   Initially focused on the practical applications of operant and classical conditioning models, behaviour therapy evolved into cognitive-behaviour therapy. While cognitive behaviour therapy has been shown to be an efficacious treatment for the past twenty years or more, the field continues to evolve.  Dr. Martell will discuss the past twenty years of CBT from the perspective of a consumer of, as well as a contributor to the literature.

David Miklowitz

The Role of the Family in the Course and Treatment of Bipolar Disorder

David Miklowitz,
University of Colorado, USA

Bipolar disorder is a highly debilitating illness that affects as much as 4% of the adult US population. Its recognition in childhood is relatively new. Although its primary treatments are pharmacological, there is increasing evidence that adjunctive psychosocial interventions are effective in preventing relapses and stabilizing the symptoms of bipolar disorder.  This talk describes a research program investigating the role of family attitudes and communication patterns in the course of bipolar illness, and family intervention as adjunctive to medications in stabilizing illness course among adults and youth. Several randomized controlled trials conducted by our group demonstrate that adjunctive family psychoeducation delays recurrences and reduces symptom severity among adult patients followed over 1-2 year periods.  Results of a two-site trial of family-focused treatment for adolescent bipolar disorder are reviewed. Our research has begun to clarify some of the psychosocial mechanisms by which family treatments achieve their effects, including enhancing the emotional climate of families and improving the interface between psychosocial and pharmacological treatments.  A study of family treatment in delaying the initial onset of bipolar disorder in children aged 9-17 is described.

Jack Rachman

From Conditioned Reflexes to Catastrophic Cognitions: An Evaluative History of Cognitive Behaviour Therapy

Stanley Jack Rachman,
University of British Columbia, Canada

The evolution of cognitive behaviour therapy, from Pavlov’s discovery of conditioning processes to catastrophic cognitions, is described. The growth of behaviourism, largely as an alternative to unsatisfactory introspectionism, gradually influenced the study of abnormal behaviour, and particular attention was paid to the nature and modification of fear. The later growth of cognitive psychology had an indirect influence on therapy and about twenty years ago a fusion between cognitive and behaviour therapy started—cognitive behaviour therapy. The ideas that initiated and promoted these developments, including the ideas that failed, are analysed. Early and current criticisms of behaviour therapy and cognitive behaviour therapy are closely examined and some recommendations are offered.

Paul Salkovskis

Twenty Obsessional Years, Compulsive Research with a Few Doubts Feels Just Right

Paul Salkovskis,
Institute of Psychiatry, UK

Reassuringly, twenty years of research has resulted in a reduction in stigma and better treatment for those suffering from obsessive compulsive disorder. Key developments will be reviewed, particularly focussing on the way that cognitive theories have helped with the issue of normalising and destigmatising. The impact of the continued tension between psychological and biological approaches will be considered. Some important gaps in our understanding will be identified. The likely course of future research and how this might further improve treatment will be considered. 
 

Max Birchwood

CBT for Psychosis: Change of Direction Needed to Avoid No Through Road Ahead?

Max Birchwood,
University of Birmingham, UK

The cognitive models and the cognitive therapies of psychosis (CBTp) have grown massively over the last 10 years and are now recommended in the NICE guidelines for schizophrenia and equivalent protocols elsewhere in the world. This has given license to the positive re-engagement of the person behind the psychosis and some cognitive models argue that the person and his psychosis are essentially co-terminous. I believe there are clear signs that traditional CBTp is heading for troubled waters: the Tarrier and Wykes meta-analysis has shown that, in common with many health interventions, the advance of better controlled trials have led to declining effect sizes, from .48 to .22 in the methodologically rigorous studies. Recent studies in Holland/Belgium and the UK confirm this trend with the London PRP study (n=301) showing no effects on psychotic and emotional symptoms at 12 or 24 months (following an acute episode at baseline). Drawing on our research and that of colleagues elsewhere, I will argue that we need to radically change direction in the theory and practice of CBTp to embrace: 1. CBTp as an intervention effective only for emotional dysfunction in psychosis, congruent with the foundations of CBT, 2. new evidence for different affective and cognitive pathways, 3 ‘Real time’ methodologies, 4. Bringing a new framework of social context, ‘social defeat’, into our thinking and 5. Agreement on new primary outcomes including the abandonment of the PANSS etc, which has derailed our thinking. I will outline my fantasy NICE guidelines for CBTp for 2018.
 

Philip Kendall

Flexibility within Fidelity: Clinical Procedures And Manualized Interventions

Philip Kendall,
Temple University, USA

Following a consideration of the positions for and against manual-based interventions, discussion will address the considerations pertinent to clinical practice.  A rapprochement, in which flexibility plays a part of clinical applications, within treatment fidelity, will be proposed. Fidelity to treatment strategies will be described and discussed, and examples of flexibility within fidelity for select treatment programs will be provided.

William Yule

CBT in the Treatment of PTSD in Children and Adolescents: Twenty Years Development and Current Issues

William Yule,
Institute of Psychiatry, UK

Children and adolescents can develop chronic traumatic stress in response to life-threatening events.  This paper will trace the developments in treatment over the past twenty years, in particular those since the first paper I gave at the World Congress in Edinburgh. 

While treatment outcome studies with child disorders continues to lag scandalously far behinds those with adults, sufficient studies have been published to be able to recommend further work on trauma focused CBT, EMDR and Narrative Exposure Therapy. War and disasters bring their own demands for large scale interventions that require a very different approach to that of individual or even family interventions.

In all of these developments, paying more attention to cognitive processes is paying off in relation to maximising treatment effects.

 

Chris Fairburn

The Broader Implications of the Research on the Treatment of Eating Disorders

Christopher G. Fairburn,
Oxford University, UK

The research on the treatment of eating disorders has implications beyond this specific field.  In this presentation four topics will be addressed:

  1. The advantages of adopting a transdiagnostic perspective
  2. The value of unexpected findings
  3. Do “complex patients” need complex treatments?
  4. The importance of not neglecting the basics.

It will be argued (with the support of data) that with regard to each of these topics widely held assumptions may not be valid.

 

Kelly Brownell

Treatment vs. Prevention: Obesity and World Nutrition as the Exemplar

Kelly Brownell,
Yale University, USA

Obesity carries massive human and health care costs and now exceeds undernutrition as the world’s chief nutrition problem. After decades of neglect, the developed countries now attend to the issue, but follow the usual medical model of funding studies on genetics, biological mechanisms, pharmacology, and treatment. This creates the false hope that what is a public health problem will yield to a medical approach. Further, the community of treatment professionals has convinced itself that it is helping when it is not and as a consequence, prevention has not assumed the key role the situation mandates. Real change will occur only with real change. Prevention requires understanding the broad social drivers of the problem and bold, courageous action to affect public opinion, the law, legislation, and regulatory landscape. Such action will be discussed, but in addition, there are important ways that treatment professionals and psychology and psychiatry researchers can contribute.

Stephen_Morley

‘Twenty Years Ago Today’ - Developing Treatments for Chronic Pain

Stephen Morley,
University of Leeds, UK

CBT informed treatments for chronic pain are relatively well established in the field of behavioural medicine. In this presentation I will briefly review the evidence for the effectiveness of this approach and highlight the progress that has been made in the last 20 years.  I will identify some problem areas that I think need our attention and suggest areas where we might make progress in the next 20 years.  At the heart of these problems are issues about how we conceptualise chronic pain (several models will be noted); the consequences of these models for measurement and the specification of outcomes; and some technical issues about how we might improve the design, analysis and interpretation of the data.
 

Richard Hastings

Intensive Applied Behaviour Analysis Intervention for Children with Autism: Evidence Base, and the Translation into Practice

Richard Hastings,
Bangor University, UK

Early intervention to teach skills to children with autism has been recommended by several evidence reviews and in national and international guidance. Perhaps the strongest evidence base exists currently for methods using Applied Behaviour Analysis (ABA) techniques. ABA is a science that continues to develop and is also emerging as a professional practice with its own international accrediting body. In this presentation, I will: (a) evaluate recent evidence for the effectiveness of early and intensive application of ABA for children with autism and their families including our UK-based study the Southampton Childhood Autism Programme (SCAmP), (b) consider the variability in outcome for individual children, with reference to secondary analysis of data for several hundred children, and (c) explore the challenges and future research questions associated with refining and delivering ABA-based interventions in practice.
 

Mick Power

The Cognitive Function of Emotion

Mick Power,
University of Edinburgh, UK

Emotions are functional. In multi-goal multi-purpose systems, emotions serve to provide both rapid goal adjustments for the immediate survival of the individual, and longer term adjustments to valued goals, roles and relationships. An overview will be presented of the SPAARS approach in which this functional approach has been outlined. Consideration will then be given to some of the emotional disorders in which the functional can become dysfunctional. Data will be presented on depression, PTSD, and eating disorders that illustrate the role of basic emotions and of emotion regulation strategies in the development and maintenance of emotional disorders.

Marcel van den Hout

Basic Processes Research: Past, Present and Future

Marcel van den Hout,
Utrecht University, The Netherlands

The presenter will review how paradigms from experimental psychology got borrowed and adapted in order to study the cognitive psychology of emotional disorders. Hope was created for an encompassing cognitive morphology of emotional disorders and for new treatments, based on laboratory findings.
What hopes were realised and what were not? Some thoughts and observations are formulated on the present state of CBT related basic processes research. Attempts will be made to disentangle what types of basic processes research are clinically more fruitful than others.
Finally some thoughts are formulated about the (near) future of basic process research and the relation between the basic processes research that CBT colleagues are familiar with and present cognitive neuroscience approaches.
 

Tom Borkovec

Past, Present, and Future

Tom Borkovec,
Penn State University, USA

Tom will reflect upon his experience with behaviour therapy over the past 40 years, looking for some of the significant principles and constructs that have guided its (and his) evolution to the present. These (and deductions from them) will likely influence the future of our field, and will include such domains as:

- Nonlinear dynamical systems
- Development of interventions grounded in basic knowledge
- Experimental evaluation of the efficacy of therapies
- Search for mechanisms of change
- Importance of analogue research
- Strengthening of opposites
- Determinism and freedom (habit and flexibility)
- Synchrony/Desynchrony


Richard McNally

Controversies in Our Field, Then (1988) and Now (2008)

Richard McNally,
Harvard University, USA

The purpose of my talk is to consider how certain controversies that emerged in our field 20 years ago have evolved since then.  One concerns how cognition can best be studied in cognitive-behaviour therapy (CBT)  Cognitive Psychology and Emotional Disorders, a now-classic text published by Williams, Watts, MacLeod, and Mathews in 1988, heralded the arrival of the information-processing approach  - one strikingly different from traditional cognitive approaches relying on introspective self–report.  Debates about theory and method regarding cognition and anxiety disorders, in particular, have illuminated a solution.  Another controversy, concerning the reality of repressed and recovered memories of sexual abuse, was also linked to a book published in 1988, Bass and Davis’s The Courage to Heal.  The ensuing “Memory Wars” wracked the field of traumatic stress studies for years, and now a solution to the controversy is at hand, one different from either the repression account or the false memory account.  Finally, a third controversy, especially heated in 1988, was whether pharmacotherapy or CBT was most effective for panic disorder and other anxiety disorders.  Yet an entirely unexpected development has arrived circa 2008: the use of a drug approved for tuberculosis that has no psychoactive properties by itself yet bolsters the extinction learning integral to exposure therapy.

Susan Mineka

Common and Specific Risk Factors for Mood and Anxiety Disorders: Time 1 and Initial Prospective Results from a Longitudinal Study

Susan Mineka,
Northwestern University, USA

Anxiety and mood disorders frequently begin in adolescence and may leave lasting scars into adulthood. My colleagues and I (Michelle Craske, Richard Zinbarg and Emma Adam) are conducting an 8-year longitudinal prospective study of over 500 seventeen year old adolescents a majority of whom were at risk for mood and anxiety disorders.  In this study we are examining personality, cognitive, information processing, and several biological risk factors for these disorders and their comorbidity. We are also examining the relative predictive utility of the many different measures of vulnerability that we have included. Many interesting findings have emerged from the initial cross-sectional results. Provocative initial results from the first 24-month follow-up will also be presented.

Lars Goran Ost

Efficacy of the Third Wave of Behavioural Therapies: A Systematic Review and Meta-Analysis

Lars-Göran Öst,
University of Stockholm, Sweden

During the last two decades a number of therapies, under the name of the Third wave of CBT, have been developed: Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), Cognitive Behavioural Analysis System of Psychotherapy (CBASP), Functional Analytic Psychotherapy (FAP), and Integrated Behavioural Couple Therapy (IBCT). The purposes of this review of the third wave treatment RCTs are: 1) to describe and review them methodologically, 2) to meta-analytically assess their efficacy, and 3) to evaluate if they currently fulfil the criteria for empirically supported treatments. There are 13 RCTs both in ACT and DBT, 1 in CBASP, 2 in IBCT and none in FAP. The conclusions that can be drawn are that the third wave treatment RCTs use a research methodology that is significantly less stringent than RCTs in CBT; that the mean effect size is moderate for both ACT and DBT; and that none of the third wave therapies fulfils the criteria for empirically supported treatments.
 

Chris Williams

Stepped Care or Matched Care?: Stepping Stones Across the Pond

Chris Williams,
University of Glasgow, UK

In both England (Increasing Access to Psychological Therapies – IAPT) and Scotland (Living Life Project) there are major developments in new ways of working to increase access to cognitive behaviour therapy (CBT). These approaches raise fundamental issues about what CBT is, and how it is best delivered and accessed. However, the stepped care model has an underlying assumption - revealed in language such as “stepping up” and “stepping down” that there is a hierarchy of intervention with “the best” treatments being access to face-to face, one to one, specialist CBT with a supervised expert practitioner. However 40-50% + of people often fail to engage with this “gold standard” showing that for many this approach isn’t optimal. We often label those who fail to engage as people not suited/psychologically minded enough for therapy - and quickly discharge them from services. The concept of matched care provides a better solution for service providers- and crucially moves the focus to user needs. Matched care introduces the ideas of choice and appropriateness as the deciding factor in what is offered, where is offered, and how this is supported. We now know for example that CBT self-help can be very effective, but only when support is offered. The support can be face to face or by phone, and doesn’t require additional therapy or for delivery to be by a mental health professional. Using this approach, the steps offered are better seen as a number of stepping stones, which the person can use to metaphorically pass to the other side - improvement. To attain this challenges us as practitioners. We need to consider our language, how and where we work, our beliefs about what is best and how offers it, our attitudes to risk, treatment goals and also to training and supervision. By doing so we can address the fundamental questions people ask- “why do I feel like I do”, and “how can I change?”

Peter Kinderman

The Rise of CBT … and Some Thoughts for the Future

Peter Kinderman,
University of Liverpool, UK

This talk will briefly outline the rise in the popularity and spread of cognitive behavioural therapy (CBT). I will examine the extensive evidence-base for the clinical effectiveness of CBT – as well as the evidence for CBT’s lack of effectiveness. I shall argue that such clinical effectiveness of CBT is based on sound psychological science. I shall argue that CBT is not a panacea, but is rather a set of techniques that apply the practical and therapeutic consequences of the findings from cognitive psychology.
I will suggest that the systematic reviews conducted as part of the development of the NICE clinical guidelines clearly establish the potential benefits of CBT, and that therefore investment in this approach is entirely justified.
I shall argue, however, that examination of a range of Government policies in this area (including the IAPT programme, the ‘New Ways of Working Programme’ and proposals to introduce statutory regulation for psychological therapists) reveal the complexity of the situation – psychological therapies cannot be purchased and prescribed like drugs; coherent plans for the provision of services must be developed.
My talk will conclude with some suggestions for what such services should look like.
 

Mark Freeston

Clinical Art and Clinical Science In CBT: Challenges For Dissemination, Education, Training and Supervision

Mark Freeston,
Newcastle University, UK

Cognitive behaviour therapy has never had such a high profile in the UK as it does now within the NHS, within government and in the eyes of the public.  There is a similarly increased profile and increased demand for CBT in many other parts of the world.  Thus CBT is operating in a climate of not only unprecedented popularity and demand but also unprecedented political and public scrutiny.  With empirical support for significant parts of theoretical models and an evidence base that supports its efficacy for a range of problems, CBT rightly prides itself as an empirically supported or evidenced based therapy.  Although there is still debate about the applicability of these findings to routine practice as effectiveness research is still relatively scares, the clinical science basis of CBT continues to grow and develop.  However, there are many important areas of clinical practice that still lie beyond the boundaries of the evidence base.  Further, many believe that some of these areas are critical to effective practice. When watching experts operate in these areas, three characteristics stand out. First, there is a simultaneous attention to both the fine detail and the overall creation.  Second, there is a seamless blend of solid technique and in-the-minute improvisational response to what is happening.  Third, when asked about what they were doing and why, experts can usually state an underlying rationale, an awareness of multiple possibilities, but also a clear sense of why it had to be exactly this way at this point in time.  At times one may thus have the impression that this is indeed clinical art.  This presentation addresses some of these key areas of clinical practice, reflects on the gaps between clinical science and clinical art, and examines how the evidence base is expanding and how some of the gaps may be addressed.
 

Jacqueline Persons

Case Formulation-Driven Cognitive-Behavior Therapy

Jacqueline Persons,
University of California, USA

The cognitive-behavior therapist who is striving to provide evidence-based care confronts many dilemmas in his/her efforts to do this, including patients who have multiple disorders and problems that are addressed by multiple empirically-supported therapies (ESTs); patients who refuse, cannot implement, or fail to benefit from the ESTs; and those who have problems for which no ESTs are available. In cases like these, the therapist faces the challenge of providing care in a way that meets the needs of the patient at hand, provides a systematic guide to clinical decision-making, and is evidence-based. My solution to this challenge is case formulation-driven CBT. In case formulation-driven CBT, the therapist conducts a careful assessment to develop an individualized formulation and treatment plan for the case at hand, obtains the patient’s informed consent to the proposed treatment, and monitors the process and outcome of the therapy at every session, revising the formulation and treatment as needed. I describe case formulation-driven CBT and present some data supporting its use to treat anxious and depressed outpatients.