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.

1 comment:

Sofie said...

I'm curious about the results... :-)