Depression Inside Out Conference Parallel Paper Session 1 Abstracts

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Felix McCoy
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1 Depression Inside Out Conference Parallel Paper Session 1 s

2 Do Psychoanalytic Treatments Offer Unique Varieties of Change? Marianne Leuzinger-Bohleber (German Psychoanalytical Association, and Sigmund Freud Institute/University of Mainz) Professor Marianne Leuzinger-Bohleber s presentation will address the important question of whether psychoanalysis produces specific changes in psychological functioning and structure. Based upon the process research done during the German multicentre LAC study comparing Psychoanalytic and Cognitive- Behaviour therapy of chronic depression (Psychoanalytische und kognitiv-verhaltenstherapeutische Langzeittherapien bei chronischen Depressionen), she will describe their findings and will propose that they are not simply attributable to changes in symptoms or mood but causally are prior to them. She will discuss how such changes differ from those offered by other kinds of psychological therapy such as CBT. Biography Professor Marianne Leuzinger-Bohleber, Dr. phil, was the Director of the Sigmund-Freud-Institut in Frankfurt a.m., Germany Currently, she is Emeritus Professor for Psychoanalysis at the University of Kassel and Mainz and member of the Scientific Staff of the Excellency Center for Research on Individual Development and Adaptive Education of Children at Risk, She is training and supervision analyst of the German Psychoanalytical Association (and former member of the Swiss Psychoanalytical Society), she received the IPA s prestigious Sigourney Award for the advancement of psychoanalytic research in 2016, and the San Francisco Psychoanalytic Centre s Haskell Norman Prize in Chair of the Subcommittees for Conceptual Research of the International Psychoanalytical Association ( ), and since 2009, Vice-Chair of the IPA s Research Board, she is known for her endeavours to integrate clinical and extraclinical research in psychoanalysis. Other research areas are psychoanalytical developmental research, prevention studies, interdisciplinary dialogue between psychoanalysis and literature, educational sciences and the neurosciences. She has published more than 350 articles and authored or edited 50 books. She is responsible for several large research projects including the Psychoanalytische und kognitiv-verhaltenstherapeutische Langzeittherapien bei chronischen Depressionen (Psychoanalytic and cognitive-behaviour therapy of chronic depression Depression study), the EVA Study (evaluation of to psychoanalytic prevention projects for children- at-risk ; FIRST STEPS- a prevention project for migrant families and STEP-BY-STEP, a pilot project for supporting refugees in a first arrival Institution.

3 Two types of mothering: depressed men and their mothers Caroline Garland (British Psychoanalytical Society) I shall present material from the treatment of depressed male patients predominantly in once-weekly psychoanalytic psychotherapy. As we know, parents and primary caretakers - but perhaps especially mothers - are central figures in all our lives. Their existence, whether alive or dead, whether in the external or the internal worlds, continues throughout our lives to affect our perceptions, emotions and intimate social behaviour. During the treatments of several men in the Tavistock Adult Depression Study (but as well in other contexts), I became aware, broadly speaking, of two distinct styles of mothering that characterized the early experience of these patients. I describe one as too little (in some way, unavailable), and the other as too much (in some way, intrusive). These in turn seemed to lead to two types of the experience of loss: the outcome of too little tended to be a sense of having been deprived; the outcome of too much was often associated with a savage sense of betrayal, often in an obviously oedipal configuration. Both resulted in chronic anger with the object, sometimes directed towards the self, leading to states of chronic depression, and sometimes suicidality. As well, there were characteristically severe difficulties with working through and mourning. All but one of these patients was seen in an individual treatment. However, I conclude with the suggestion that group psychotherapy may offer particular opportunities for the treatment of vulnerabilities or failures in the development, and the resolution of the troubled Oedipal issues that took different forms in the two groups of the patients I describe. Biography Caroline Garland is a Fellow of the BPAS, and was one of the clinicians on the Tavistock Adult Depression Study. She worked at the Tavistock Clinic for 25 years, where she specialised in the treatment and understanding of trauma; and as well in the use of group processes as a powerful and effective form of psychological therapy.

4 "This is a waste of time!": Desperation and development in an adolescent boy using Short-Term Psychoanalytic Psychotherapy (STPP) Margaret Rustin (Tavistock and Portman NHS Foundation Trust) & Ben Yeo (Oxleas NHS Foundation Trust) This paper charts the development of a fourteen year-old boy in a treatment of STPP (Short-Term Psychoanalytic Psychotherapy). The boy had an extensive history in Child and Adolescent Mental Health Services and started the treatment depressed and unable to attend school. The patient used his psychotherapy sessions, and the planned breaks between sessions, to express anger and desperation. The capacity for the treatment to contain these feelings in both the individual work and the parallel parent work, helped the patient move out of his depressed state of mind and connect with feelings of potency within himself. 'Time' is an over-arching theme of the paper and the treatment itself. Biographies Margaret Rustin was a member of the Steering group of the STPP arm of the trial and a joint author of the STPP Manual, now published as Short-term Psychoanalytic Psychotherapy for adolescents with Depression (Karnac 2017). Ben Yeo is a Child and Adolescent Psychoanalytic Psychotherapist working in two specialist CAMHS teams in Oxleas Foundation Trust in the National Health Service. Ben trained at the Independent Psychoanalytic Child and Adolescent Psychotherapy Association (IPCAPA) at the British Psychotherapy Foundation. Previously, he worked for Tower Hamlets Local Authority and The Children's Commissioner for England. Ben is pursuing doctoral research about fathers' engagement in their young children's play.

5 Unto those that have even more shall be given? Greater or less benefit in different patients and their therapies Felicitas Rost (Tavistock and Portman NHS Foundation Trust) & Imke Ahlers (Tavistock and Portman NHS Foundation Trust) A central aim of the Tavistock Adult Depression Study was to address the paucity of evidence relevant to the treatment of individuals whose depressions are long-term and relapsing. At the end of the 2-year posttreatment follow-up, the TADS primary measure of outcome showed that 44% of those receiving the psychoanalytic treatment no longer met the threshold criteria for chronic major depressive disorder. This finding offers important empirical evidence that long-term psychoanalytic psychotherapy (LTPP) provides a more effective approach for some patients compared to NHS treatment-as-usual (TAU). Despite this substantial benefit, 29% of the psychoanalytic patients did not improve, 14% showed significant improvement at the time the treatment ended but did not sustain these over the two year follow-up, and 15% dropped out during the treatment. This panel will present the preliminary findings of two studies we have undertaken in order to understand the factors behind these differential treatment effects, and to examine the possibility of different categories of change. The two studies approached their questions in different ways: A qualitative methodology was used to address the individual s experience and subjective meaning-making to bridge the gap between primary clinical level data and quantitative outcome group level data. We used thematic analysis to analyse the Private Theories Interviews (PTI, Werbart et al 2006) carried out with 40 of the patients who completed the psychoanalytic treatment. Imke Ahlers will describe patients experiences of their treatment and their private theories about what was helpful or unhelpful that in their view contributed to the change or lack of change they experienced. The emerging themes among patients falling within three groups were compared and contrasted. They were: those who had not benefitted in terms of depressive symptom reduction (n=21), those who showed benefits at the treatment s end but relapsed during the 2 year follow-up (n=7), and those who showed gradual improvements over the followup, namely those manifesting what is often called the sleeper effect (n=12). The findings indicated that there were substantial differences between these groups in terms of how individuals formulated change and in their experience of helpful and unhelp factors in therapies. As well, our findings point to a need for future research to include a wider variety of outcome variables than those based narrowly on symptom change. Felicitas Rost will present her findings with a newly developed empirical measure informed by a psychoanalytic framework, The Anaclitic-Introjective Depression Assessment Q-sort (AIDA, Rost, Fonagy & Luyten, 2017). She found differences existing amongst TADS patients in terms of underlying personality structure and function that predict the differential treatment effects independently of depression symptomatology. Two more maladaptive (Submissive and Dismissive) and two less maladaptive (Needy and Self-Critical) sub-dimensions were identified respectively of dependent (or anaclitic) and self-critical (or introjective) depression. Multi-level modelling was used to compare the individual s trajectory of depression severity over both the treatment period and the 2-year follow-up. In addition, rates of remission and clinically significant change were determined. Depressed patients with less maladaptive dependent and self-critical features typically showed considerable gains in both treatment conditions, with medium to large effect sizes. Patients with more maladaptive features did not benefit either from the LTPP or TAU. Findings have potential implications for the conceptualization, diagnosis, and treatment of chronic or treatment-resistant depression. They may point to the need of tailoring treatments including psychoanalytic ones - according to the pre-treatment features of individual personality configurations.

6 Biographies Felicitas Rost, PhD. Research Lead at the Portman Clinic, Tavistock and Portman NHS Foundation Trust & President of the Society for Psychotherapy Research (SPR) UK Chapter. Dr Rost s professional identity and current interests are shaped by two beliefs: The necessity of building bridges between psychoanalytic treatment modalities and empirical research; and the breaking down of arbitrary dichotomies between research modalities. She has been the project coordinator and senior researcher of the TADS from 2009 onwards and integrated a qualitative arm and process-outcome link into the main outcome trial. She joined the Portman Clinic in 2015 where she is currently leading on the development of the clinics research strategy to advance a body of knowledge on criminality, compulsive sexual behaviours and violence and of its treatment process and outcome of individual and group psychoanalytic psychotherapy. Imke Ahlers, BSc. Assistant Psychologist, Tavistock and Portman NHS Foundation Trust & MSc student in psychoanalytic developmental psychology at the Anna Freud National Centre for Children and Families. Miss Ahlers became involved with the TADS in 2016 when she began the qualitative analysis of the Private Theories Interviews of the TADS patients. She utilising some of the data to complete her BSc thesis in Rehabilitation Psychology from the University of Applied Sciences Magdeburg-Stendal in Germany. She is also currently supporting the Portman Clinic research programme as an honorary research assistant, carrying out both assessment and qualitative interviews with patients reporting problems with criminality, compulsive sexual behaviour or violence. Both experiences have fostered a keen interest in the consequences of developmental adversities, qualitative methodology and process-outcome psychotherapy research.

7 The gold standard is already a barbarous relic Weighing up RCTs, guidelines and the Tavistock Adult Depression Study Susan McPherson (University of Essex) Contributing Chair: Dr Julian Stern (Tavistock and Portman NHS Foundation Trust) When the UK introduced its Gold Standard in 1821, the value of the sovereign was fixed to the weight of pure gold. For a while, the system seemed to work. But after WW1, the economies of many nations experienced severe depressions. Despite considerable evidence that gold standards were part of the problem, governments clung to them. This led Keynes in 1923 to declare the gold standard a barbarous relic. Similarly, NICE appears as if transfixed by a putatively pure gold standard, in its case founded on the merits of RCTs for treatments of physical disorders but omitting to weigh the actual RCTs done against what is known scientifically of mental disorders (for example, the natural history of depression), and thus what a proper test of their treatment requires (for example, proper follow-ups). As noted by Jonathan Shedler, most scientific knowledge does not come from RCTs. NICE s version of evidence based medicine in the form of guidelines is a version that may never have been suited to weigh up psychological therapies or, arguably, for improving services and treatments for mental disorders generally. Critical feedback from service users, clinicians, GPs, commissioners and researchers on NICE guidelines seems to have limited impact as NICE clings to its relic. To understand these contradictions, this presentation turns to Lindsey McGoey s (2010) idea of strategic ignorance i. Based upon game theory, it gives insight into how limiting information that is clearly relevant can, paradoxically, be a valuable strategy in maximising the probability of a desired result. NICE s treatment of the findings of the Tavistock Adult Depression Study (TADS) is a case in point. TADS met the criteria for earlier NICE guidelines for depression. Yet the NICE 2017 revision deemed it of very poor quality and omitted the study s exceptional two years of post-treatment follow-up outcomes along with all follow-up data from other RCTs. The idea of strategic ignorance applies equally to the psychotherapy research community s own participation in what might be described as the Game of RCTs. Again, taking TADS as a case in point, the instigators were aware of the limitations of the RCT paradigm, yet chose to play by what they thought were the rules, on the assumption that other things being equal the treatment under study would be granted entry. With the benefit of hindsight, they neglected to consider that the rules of subsequent NICE mental health guidelines would change, the goalposts shift, and the decisionmaking be opaque, while at the same time, the claim to uphold the RCT gold standard could be maintained. This presentation will also present qualitative data on service users understanding of the TADS RCT and views on the treatment should be weighed up. It is proposed that service user views should be at the heart of a new paradigm to evaluate psychotherapies. Generally, the implications of what we know scientifically should be treated much more seriously. Going along with a medical model and an evidence based paradigm that is systematically unhelpful and misleading will not work either politically or strategically and cannot improve the care available for people suffering from the enduring effects of early lives that were often much less than ideal. Contributing from the chair, and from his position of holding responsibility for maintaining services in the current context, Julian Stern will offer a critical perspective, before opening these complex topics for general discussion and comment. Biographies Susan McPherson is senior lecturer at the School of Health and Social Care at the University of Essex. She studied social psychology at LSE, health psychology at UCL and has a PhD in medical sociology from King

8 College London. She was a research psychologist at the Tavistock Clinic from and was a leading member of the research team that undertook the Tavistock Adult Depression Study Her PhD explored the management of long term depression in primary care and critical approaches to psychiatric diagnosis. She has published and supervised a wide range of qualitative and quantitative research relating to the experience and management of depression and related topics. Dr Julian Stern trained in Psychiatry and Psychotherapy at the Maudsley Hospital, and at the Lincoln Centre, now part of the BPF (British Psychotherapy Federation). For 17 years he headed the unique Psychological Medicine unit at St Mark s Hospital, Harrow, a hospital for patients with gastrointestinal disorders, before moving to the Tavistock Centre in 2010, where he has worked as Consultant Psychiatrist in Psychotherapy. In 2016 he was appointed director of Adult and Forensic services in the Trust. He has a special interest in patients with Medical symptoms and disorders.he has published widely, in medical, psychotherapy and psychiatry journals and is co-editor of the popular textbook Core Psychiatry. Lindsey McGoey (2010) used the term strategic ignorance to describe how Irving Kirsch engaged in a Maudsley debate The Drugs Don t Work to suggest that engaging proponents of RCTs simply on the technical details of what RCTs of antidepressants show involves a strategic act of ignorance when, like many of us, Kirsch thought, and might rather have argued, that the paradigm was faulty.

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