Saturday, April 20, 2013

Render unto CCESA

Entry for 20 April 2013:

The draft NICE guidelines for Social Anxiety (SA) were issued last December.  Anxiety difficulties in general, and social anxiety in particular, has been a bastion for behaviour therapy and cognitive-behavioural therapy since the 1960’s and even 1950’s.  In 1976 I was learning an early form of CBT, working with a client with social anxiety.  Over several weeks, I had taken her through progressive relaxation and we had constructed a hierarchy of social-interpersonal fears.  One day, about halfway through the hierarchy, she suddenly became overwhelmed, burst into tears, and ran out of room.  I followed her out into the hallway, where she stood, crying.  I asked her if she would be willing to come back in and tell me what had happened.  She said that she would if we stopped with the hierarchy.  I was happy to do so, and we then worked for many months in a broadly psychodynamic manner, including exploring her fear of abandonment as a child. I can no longer remember whether her social anxiety had improved much by the end of our work, but I do remember that she was less depressed and felt better about herself.  Up to this point, I had been somewhat enamoured with behaviour therapy and had even received training in cognitive therapy (this was before Beck’s 1979 book). This however was the beginning of the end for me and CBT. 

I thought of this last December when the draft guidelines came out.  Two years earlier, I had applied to serve on the Guideline Development Group for Social Anxiety.  I was offered a place; however, after several exchanges with the person organising it, it became clear to me that they weren’t willing to look beyond what they considered to be “good quality RCT evidence”.  “Why wouldn’t we want to look at all the evidence? “ I asked.  “There’s no need”, was the answer.  “What about emerging treatments?  Wouldn’t practitioners want to know about this?”, I wanted to know.  “That’s not the mandate”, they said.  Actually, I’d read the guidelines for guideline development groups, and had been briefed previously, so I knew that this wasn’t accurate.  Instead, it meant that they had no intention of allowing any other kind of evidence to be considered.  I said I’d think about it. 

Eventually, after further reflection and consultation, I decided to resign from the NICE Social Anxiety Guideline Development Group before it even started.  At the time, it was not that long since my cancer surgery, and I really had to ask myself whether, given my limited energy, I wanted to spend the next 18 months of my life banging heads with the various hard-science folks on the committee.  In the end, I realised that I could do more good by using that time to carry on with my own research on social anxiety. The result of my efforts was the integrated EFT model of SA that emerged with our last wave of clients.

So now I was seeing the result of the committee’s work and my decision not to take part.  Reading the draft guideline, I was not at all surprised to see CBT proclaimed as the pre-eminent psychosocial treatment for social anxiety.  This has long been clear from the existing literature, with the Heimberg and Clark-Wells models being given equal weight in the draft guidelines.  What did surprise me was that Interpersonal Psychotherapy (IPT) and psychodynamic psychotherapy were listed as second-line treatments, on the strength of only two RCTs each.  Hmm…. I thought… I’ve got half of an RCT already:  Our recent treatment development study was partially randomised between EFT and Person-Centred Therapy.  I began to feel somehow obligated to at least try for an RCT on EFT for SA.

As a result I started talking to people about a possible RCT comparing the version of EFT I’d developed for SA over the past 5 years, with one of the standard versions of CBT for SA.  One thing led to another, and eventually Richard Golsworthy and Tania Saninno (from Glasgow Caledonian University) and Rachel McLeod (from the NHS and University of Glasgow) agreed to work with me, Lorna Carrick and Susan Stephen to put together such as study, focusing on early career psychotherapists/counsellors within 5 years of their main professional training.  It was a lot of work; it has eaten up large amount of my time over the past month in particular, not to mention the anxiety about whether we’d actually be able to pull this together in time for the 12 April deadline.

Finally, about 8pm on the 10th of April, I clicked on the Send button and submitted the proposal.  It turns out that RCTs today have to have a cute acronym-based title, so ours is called “Comparison of Cognitive-Behavioural Therapy and Emotion-Focused Therapy for Social Anxiety”, abbreviated CCESA, as in “Render unto Caesar”.  I have no idea whether this will be funded or not.  Frankly, given that only about 10% of submitted grants are funded today in most countries, it’s not terribly likely.  However, to quote T.S. Eliot, “But perhaps neither gain nor loss./ For us, there is only the trying.  The rest of not our business.”

At any rate, here’s the abstract from our proposal:

Social Anxiety (SA) is a common, chronic psychiatric problem characterized by social withdrawal, significant psychological distress, and educational/employment difficulties. In NHS settings, resources and choices for effective treatment for SA are currently limited.  In a pilot partially randomised study we developed a promising SA-specific form of Person-centred/humanistic psychotherapy called Emotion-Focused Therapy (EFT), aimed at reducing SA by enhancing client self-compassion; we found large amounts of client pre-post change, superior to a comparison treatment and equivalent to comparable studies of CBT and medication. We are seeking funding for a pilot RCT study comparing this new treatment to a NICE-recommended Cognitive-Behavioural Therapy (CBT) based on the Heimberg model. Two groups of early career psychotherapists will be trained in the use of these specialist models for SA, with 52 clients assigned randomly either to CBT or EFT for up to 20 sessions.  Target outcome measures will assess SA symptoms and individualised presenting problems.

Sunday, April 07, 2013

My Mother’s 84th Birthday/Science My Mom Taught Me

Entry to 7 April 2013:

I’ve been working late to finish a grant proposal, so it’s well after midnight in Scotland, Monday, the 8th of April.  In California, however, it’s still Sunday, 7 April, my mother’s birthday.  Last year, my siblings and I gathered at Anna’s house on this day to celebrate our mom’s 83rd birthday.  We knew something was wrong then, and we also knew at the time that she believed that she had reached her last year, her 84th, the completion of her 3rd Saturn Return.  What neither she nor we knew then was that she would be dead by the end of June, a few days past the summer solstice.  So tonight her children are marking what would have been our mother’s 84th birthday by reflecting on her passing.   A little while ago, my brother Conal and sister Louisa checked with poignant reflections about both of our parents.  This is my contribution to the process.

A year ago, on her birthday, I read her 75th birthday poem to her again and gave her a mobile of multi-coloured butterflies made from bird feathers to represent the final image in the poem.  After she died I brought this mobile back with me to Scotland to remember her by, and it’s in my living room now, a bit of her. 

I know that she and my dad are in my head and heart, a part of me.  They are my psychological and spiritual DNA and of course their actual DNA is in every cell of my body. (And my mitochondrial DNA?  That’s all my mom’s, matrilineal descent, you know?)  Nevertheless, I still miss her physical presence and the opportunity to experience the unpredictability of her continuing evolution.  So tonight it’s a kind of intermediate stop on the way to her year’s mind, an interim Kaddish at which I, along with my siblings, remember fondly, longingly, and with deep gratitude and joy for what she gave us.  Bittersweet, like the strong chocolate that she loved.

I can’t think of a better way for me to remember her than by offering again the poem I wrote 9 years ago for her 75th birthday:

Science My Mom Taught Me
(For her 75th birthday, April 7, 2004)

1. Science as Love and Relationship

A good place to start is that ancient photograph,
Recently rediscovered, from 1950:

There the two of you are, the same age
As the youngest of my grad students. 
Both of you are tall, almost toothpick thin.
He is looking at the camera, tight jeans and shirt,
Like a rebel with cause to smile.

But you are looking down, through large glasses,
Your face framed by billowing hair,
With toothy grin, and your arms
Awkwardly but carefully wrapped round
A very small bundle.

The two of you look like nothing
So much as a couple of computer nerds
From half a century in the future.
Code geeks, rolling out your first promising program,
Ready for beta-testing.

But the code is genetic,
The language is life,
And the program is … me.


2. True Science is Risky

Although I learned magic from my dad,
It now seems clear to me that it was you
From whom I first learned science,
To which I have now devoted so much of my life.

But yours was never the normal, safe kind,
Digging away at the coal face
In the mines of knowledge,
Like Disney’s happy dwarves.

No, not that kind, but instead
The one that goes off to Far Tortuga,
Toward distant Galapagos unknown,
In search of the evolution of the human soul.

For you, big ideas have never been too big:
The nature of reality; the journey of the soul;
Jung’s famous paper on flying saucers;
The archetype of the Mandala: As without, so within.

Instead of Aristotle … Plato’s forms;
Instead of Archimedes … Pythagorus’s numbers;
Instead of Moses’ law … the Kabbalah’s secrets;
Instead of chemistry …alchemy’s transformations.

Oh, you did chemistry, too, at least early on:
You would disappear for hours,
Into your laboratory at the back of the house,
Full of strange smells and odd bits:

Broken glass, mosaic pieces,
Rolls of wallpaper, bolts of cloth,
Cans of precursors and catalysts,
When plastics was new technology.

And you would emerge from your lair,
To confront your family with some new concoction,
Sometimes lovely, or quirky, or primitive;
At times, a disaster, but always something new.

No, for you, science has always been risky:
Working at the edge, making something new,
You have become an expert in the peril of experiment,
And I have followed you, where I could.

3. Science as Inspiration and Passion

Your mother (my grandmother) taught me many things:
How to travel and how to be in a new place;
The importance of hard work and getting up early;
The ninety-nine percent of sweat that makes up genius.

But you taught me a far more valuable lesson:
The one percent of inspiration that redeems all the rest,
The moment of epiphany, the pattern opening,
The intensity of the new connection breaking through,

The science of cutting to the center of the world,
Of seeing what others don’t choose to see,
Of waking to awareness when others sleep,
And the flow of following the spirit far into the night.

When I see these things in myself, I recognize you.
The passion of discovery is too powerful to resist,
Even if we wanted to; the daemon must be honored;
It is ours, and we must let it speak through us or die.

4. Science as Always Starting Anew

I find it odd that I describe my dad in a series of narratives,
But you as a set of ideas, a paradigm, a model.
There is, however, one story that is always you,
The story in which you are always re-inventing yourself:

Child of the Depression with a single mom;
Big city girl; prep school party-er;
Young, anxious mother and seamstress;
Small town society woman in a flat land.

But your life makes a strange turn: You take up philosophy;
You quit smoking just because you feel like it;
You return to religion and start teaching Sunday school;
You become a small business owner and a writer.

Years pass: You’re CEO of a large and raucous family,
With the habit of taking in strays (both human and animal);
And you’ve gradually evolved into a spiritual leader
Of a small but loyal group of friends.

Then, your life turns again:  Warned in a vision
Of the impending end of civilization, you become
A gentle survivalist and take your family
Into the mountains, like Noah waiting for her flood

You seal several tons of wheat into cans,
Which are still there after twenty-five years.
Well, we can’t get everything right, but now you live
In a beautiful little valley: Murray Creek.

Now you are matriarch to three generations and 60 acres.
A combination of Ariadne, Daedalus and Theseus,
You become a labyrinth designer and unwinder
Of ritual journey spaces of stones, words and image.

Reading widely and deeply, you map the interweaving
Stories of your own and humanity’s spiritual development,
Join a religious order, become a spritual director,
And finally, start a Crone Circle of wise women.

Curiously, all these things somehow fit together:
Clearly, you’ve never stopped starting over;
For you, science is leaving behind what no longer works,
A selfsame process of adding on, differentiating, elaborating,

Just as you are always the same person,
The passionate, intellectual adventurer, the one
Who keeps transforming herself, like an endless succession
Of butterflies, emerging one from the other. 

Photo by Conal Elliott, Upper House, Murray Creek, 27 March 2013, by permission.