Dr. Jane Gilmour: Welcome to a new series of Mind the Kids. I'm Dr. Jane Gilmour honorary consultant, clinical psychologist and child development program director at UCL.
Prof. Umar Toseeb: I'm Umar Toseeb a professor of psychology at the University of York focusing on children and young people's mental health and special educational needs.
Dr. Jane Gilmour: In each episode, we select a topic from the literature and in conversation with invited authors, sift through the data, dilemmas and debates to leave you with our takeaways for academics and practitioners. Today, we're taking a deep dive into a really important topic. We're discussing different types of psychotherapy, what works and why. This episode is called Rebooting the Great Psychotherapy Debate.
Prof. Umar Toseeb: Okay, so let's talk about talking therapy. So this is a really interesting conversation for me that we're going to have today because I have specific views that I've developed over time about talking therapy. know, talking therapy is the ⁓ go-to approach for common mental health difficulties. So I think, and Jane, you can correct me if I'm wrong here, it's the first line approach when someone experiences mental health difficulties and they seek support. And so we're recording this at a time when it's ⁓ welcome week at my university and we had this session where we were talking to some students, handful of students, and I was saying why do you want to study psychology? And one person said because I want to go into therapy. So then I started my little rant about my problem with talking therapy and I was like a lot of common mental health difficulties that we talk about on this podcast and that are established in the literature are, their origins might be social. So things like bullying, adverse childhood experiences, poverty, stuff that happens in the environment around us that then contribute to mental health difficulties. And then what we say to the individual is, I'm sorry, all that stuff has happened to you. Now let's try and talk about that. But that situates the problem within the individual rather than trying to address that social structure.
Dr. Jane Gilmour: And yes. Yes, and right. have, of course, and we've talked quite a lot about these environmental issues, poverty, for example, which has a pernicious effect on mental health. And yes, we also know that for depression, conduct disorder, anxiety, trauma and so on, there is an evidence base for psychotherapy in depression. In particular, there's a range of different psychotherapies that is very pertinent for our conversation today. But I also and I, I, I take your point, but you could also argue that the idea of we're not situating a problem within a person, we're giving them the opportunity to feel better. We've given them the agency for change. And in particular, for example, cognitive behavioral therapy changes the perception of an existing circumstance. So the power to change where environmental shifts aren't feasible, we are not in charge of the economy, that we were, so what else are we going to do? We can make a change and I think it's about delivery. So for example, most of my clinical work is with young people with tics and I would offer psychotherapy, so habit reversal training or exposure response prevention and I'm not giving the message I have to fix you, I'm giving a young person the opportunity to have agency over their body. And I think that has huge repercussions for a young person. So I think it's not either or, I think it's both and.
Prof. Umar Toseeb: Yeah, I agree with you there. think my point is more we spend a lot of resource, whether that's time that we spend talking about it or research or whatever it might be on the what to do after the fact. But actually, there's lots of preventative stuff. And we know we're not we're not in charge of economic policy, but actually we do have a role in advocating for that as well.
Dr. Jane Gilmour: Yeah. so, but, but I think, I think it's not, you know, I think this, is not about diminishing the power of psychotherapy. I think it's about recognizing that intervention can take a variety of different routes. And I think one of the things about Ian's paper that we'll go into a little bit more is it's starting this debate about different sorts of psychotherapy and whether there is specific efficacy or effectiveness. And I'm really interested in these differences between psychotherapies potentially that are raised here. And it sounds to me as if you have a concern about all psychotherapies as a sort of philosophical stance. So guess there are slightly different things to say there.
Prof. Umar Toseeb: Yeah, no, I'm not against it. Obviously, like it's necessary. I would just prefer that we weren't in the situation where we needed psychotherapy, but that's not where we are. But let's bring Ian in because I think I'm sure he has thoughts. So today we're joined by Professor Ian Goodyear from the University of Cambridge. Ian is the co-author of the paper Dynamics of Depression Symptoms in Adolescence during Three Types of Psychotherapy and Post-Treatment Follow-Up published in the JCPP. Welcome, Ian. So, Jane, do you want to start us off with some questions for you?
Dr. Jane Gilmour: Yes, because I wondered, I wanted to get just to the top of the concept and the ideas that you've raised in your paper. I wondered if you could describe for our listeners Wampold's great psychotherapy debate and in particular what your thoughts are. Bring us up to date in the context of your recent findings well as you know psychotherapy is not new and what Bruce Wampold was doing after many many years of highly respectable research himself was trying to gather together a set of information probably over about 50 years of work his own and others and try and put the point to all of us that there were more similarities between psychotherapy schools than the psychotherapy schools themselves wished to acknowledge. So the point here is that, yes, they look different. They have huge theoretical differences. People have used anecdote and theories and some empirical work to try and emphasize the differences. The differences therefore influence how you train and educate people in the underlying theoretical frameworks of the mind that you need to be aware of. Trainings have got longer and longer and longer over the time as though somehow the more time you spend in some kind of obedient form in the therapy that you're learning the better you will be for which there's very little evidence and he came to the conclusion that we needed to have a reset and he wrote number of papers but I think everyone will probably know the book that he published I think in about 2020 or so, can't quite recall anyway he had two basic premises ⁓ first of all the great debate centers around commonality and disparity between the psychotherapies common didn't mean necessarily things that anyone could do, but it did mean things that therapies shared and therapists might share. And that common mechanism concept has actually been established time and time again since that book. Meta-analyses by the Dutch group, led by Kuipers, have shown that ⁓ probably more variance is occupied by the common mechanisms than by the specific. There are problems with that because of the nature of the level of measurement and understanding about what could be common and what could be specific. But nevertheless, this is the great kind of debate that Wampold worked on and he talked about dropping the idea of specific therapies which suggested that there were modular mechanisms that each therapy uniquely had possession of that would make a difference to the patient and he said no there are contextual factors that all therapists have a view on but they actually share and you're all being a bit defensive about the situation. What really matters is that we understand the common features and then we ask the question, well, are there different specific issues that each of the therapists can bring in order to obtain a similar result? The concept of equifinality has actually never been questioned that much. That is to say you can get to the end road by different pathways but you'll all end up doing something useful and therefore measurements, utility measurements of being useful will actually show the same characteristics across therapists, across therapy, across therapists in order to get the right outcome. So that begs the question, what are the common features? and it was interesting listening to the two of you talk about the environment versus the internal world because the common features contain both and for Wampold what was important more important than anything it appears in his writing is the relational aspect of the therapist and the individual knowing the environmental context from which the individual comes so I would kind of say to both of you and to anyone listening, first thing you should do if you're to be a therapist is learn how to take a history, do a proper assessment, come to a formulation and determine what in your view might be the best way forward, which you then check with the client, patient, maybe the family, in order to develop a collaborative contextual framework as you set out on the journey of therapy. I think the biggest concern I have at the moment is that we're not educating our therapists, many of whom are not academic psychologists or psychiatrists. fact, many of them seem to me to be young. The age seems to be dropping. They're working in difficult environments in a professional sense, and they must be taught and must be helped and supported to do proper assessments. I think that would be the first place, particularly if you accept Wampold's view that context really matters context in terms of the environment people come from, context in terms of what the therapist brings, and context in terms of that relational process. He also noted... ⁓
Dr. Jane Gilmour: And I think that's a route, sorry to interrupt you, and I think that's such an important point, because for example, if you're training wellbeing practitioners who are low intensity ⁓ interventions, but actually coming across by virtue of the complexity of mental health referrals, coming across quite complex cases and helping those younger or early career practitioners to understand the contextual complexities that may be outside their prescribed protocol is actually one of the challenges because we don't want to stop families getting access to treatment, but nor do we want wellbeing practitioners or early career practitioners intervening where in fact the presentation is more complex. So I think that's a really pertinent point.
Prof. Ian Goodyer: I think that's a very good summary. I think that the ⁓ specificity issues within therapists are not to be forgotten, but it might be something that ⁓ Wampole's work didn't quite get at, is what would those techniques be that would distinguish people? I mean, if it's a conversational approach, there's one underlying philosophical dilemma that you didn't mention that I will suggest to you, that unlike any kind of intervention in healthcare, whatsoever. Psychotherapists, whatever their school and their beliefs and their own values and so forth, are prescribing themselves. There is nothing else that does that. So when you put yourself on the line in a randomized controlled trial, it's not the same as prescribing a tablet, a pill, a catheter, or indeed a public health outcome such as changing the environment in a school, which is going to be tried more more over the next 30 years. So it's difficult. The defensiveness that one is so explicitly sees amongst psychotherapists of any kind is because they've spent years learning things and now somebody's come along and saying, well they're quite important, but you know they're not the only thing and anyway you could have probably done it in 10 minutes instead of 27 and a half hours a week and so forth. So it's not surprising that it's awkward to get implementation and delivery into the places where it really matters and I agree with you Jane, the young wellbeing practitioners are a vulnerable group professionally speaking because I'm worried about what it is that we're teaching them and how they're going to be supervised in a very difficult professional environment at this time. But Wampold makes the point, others agree with him, it's context, it's relational and where do we go from there?
Prof. Umar Toseeb: Thanks Ian. So moving on from that, so context, relational and where do we go from there? In the paper that we're going to talk about today, you're specifically looking at three different types of talking therapies. Do you just want to talk us through what those are and maybe what their origins are?
Prof. Ian Goodyer: Sure. First of let me acknowledge all my good friends and colleagues from UCL because this study was a combination of actually four groups in the end but it started off with a gentleman called Peter Fonagy who Jane probably knows quite well and you've probably all heard of phoning me up and having a conversation about randomized controlled trial And Peter suggested that he and I applied, together with others, applied for this grant. So it was Peter that kicked this off and of course he wanted to study short-term psychoanalytic psychotherapy which wasn't getting, in his view, I think it's okay to say this, enough of a decent press given that there was more and more empirical evidence that it wasn't just CBT which has enjoyed being a front runner for 30 years now, and that other things could be brought in. So he wanted to do a study of comparing short-term psychoanalytic therapy with CBT in depressed individuals. He wanted to do this at the time that the NIHR, National Institute of Health Research, had issued a very particular call to try and understand better the talking therapies that might have effectiveness in adolescence there hadn't been much in this country and there had been a very large study in the United States which had involved a lot of antidepressants and had shown antidepressants were really valuable for some individuals but who and when and how and why and that one thing we weren't no longer needed to do was to have a control group who got nothing because it was quite clear that in that kind of standard trial of something against nothing doing nothing not a good idea didn't surprise any of us but nevertheless had now been established. So that's how we got to short-term psychoanalytic psychotherapy in CBT but I said well as you know Peter in our 2007 published randomized controlled trial we were kind of surprised at the number of young people who did rather well who were severely depressed with an antidepressant and what you might call good psychosocial support. And when we gave them CBT2, it didn't provide any added value. Now this kind of fed into the idea of Wambold's contextual and common issues because here we're using two quite different methods. Psychosocial support's pretty straightforward, problem solving, empathy, trying to keep the relationship, but not adding cognition in the way that Jane described earlier for looking at cognitive rationality and the irrational thinking that can occur in depression not adding behavioral activation in a formal way that has become a big deal in young persons therapy in general and certainly not adding things like insight and empathy in a strong sense that you would see in the psychoanalytic perspectives who are trying to make interpretations about the way people were appraising themselves in the world. So what was it that was useful if CBT made no added value? We concluded there was something about the ingredients of everyday good clinical practice that was worthwhile in pulling together and dissecting out from the general corpus of I'm talking to my patient and looking after them. So we got to the third treatment which was standard clinical care but we turned it into something we gave it a name and we call it brief psychosocial intervention. We weren't the first people to use the term BPI although that was the first time the acronym was used, but we were the first people to use it in two distinct ways. One, brief psychosocial invention came from the experience of people working in the clinic. So rather than theory-based, it's practitioner-based. Doesn't mean there aren't theories, but it was practitioner-based in how we formulated what to do. And two, it very much was out of the evidence, the continuity of evidence from our first trial, which is called the ADAPT study. So then we had three treatments. We had CBT, we had psychonautic psychotherapy, and we had BPI. And Peter and I agreed, and we got others to agree, Shirley Reynolds came on board Professor of Clinical Psychology, UEA, and then Reading, that what we wanted to do was to test it in a way that people like you guys, academics and practitioners, would believe the results. And there we move into the more pragmatic world of saying, yeah, yeah, great job, but, but look at all this all this stuff I don't believe it. So we had to make sure that it was believable and that's why we went for a big study, the biggest at the time, and we went to use only people who were really credited and able to practice those three things. So everyone who was a therapist in CBT met the approval of the specialist CBT committee that we set up to organize therapists for the trial. The same was true for psychoanalytic psychotherapy. And we also set up a similar little committee for BPI, although BPI being pragmatic and out of practice world had less as it were regulatory history to it. So we had to be a bit on the hoof about that, but that's what we did.
Prof. Umar Toseeb: Thank you. And before we move on to why they work, which I think some of the mechanisms, which is what the focus of the paper is, what is the evidence that those three types of psychotherapy do work for adolescents with depression?
Prof. Ian Goodyer: So those are our three treatments and how we got there. Okay, so now you get into the thin ice that is called the evidence base for the treatment of depressed young people. ⁓ It's thin, but it's not negligible. So actually, you can trace about a 50 year history of the anecdotes of treatment. And if you take a sort of qualitative view by accumulating all the qualitative anecdotal data you have to come to the proposition that it's reasonable to form the hypothesis that there are active elements in a professional conversation that do not exist in an over-the-garden-fence piece of advice or a chat with your mum and dad. So first of all let's step back and not get too clever and say look the heuristic that is out there is that there's something about talking to people in a professional way that seems to be useful. I think the epiphenomenal error that's been made by all of us is to think that all the theory that all of those useful people thought they knew and all the mechanisms that they thought that they were acting through their very special skills might not be true, at least might not be true in full. So I do think there was evidence. What about the empirical evidence? Well, the NICE guidelines have been about for a bit, but didn't say much about child and adolescent psychiatry since I was on the NICE committee at the time, I'm aware of that. The evidence was pretty reasonable that something about this concept called CBT and this construct called CBT therapy was doing something. The evidence was a problem and this is nothing to do with CBT therapists, but the trouble is CBT was the only thing that seemed to have been studied scientifically in any particular quantity. But it seemed to be fairly clear that despite some of the grandiose claims of the great CBT godfathers, there was no doubt that CBT was doing something that was pragmatically effective not very but a little bit inflated.
Dr. Jane Gilmour: I read that, I think it was 2019, the NICE committee were moving somewhat, but very cautiously, there was a lot of couch language that psychodynamic psychotherapy might be appropriate in some cases of childhood depression, but it was very, it was very cautious, a very cautious recommendation, I would say.
Prof. Ian Goodyer: Yeah, I think that's like a meeting of the great churches asking how they, whether or not there isn't a common way of coming towards this concept of agency and God. They do it very cautiously, let's be honest, because they've got a congregation to worry about, not to mention their jobs. So I think it's the same with psychotherapists, that coming cautiously, it's still the case, and it's still the case in the UK, that the dominant landscape for psychotherapy is CBT. In the very general sense, I think as David Clark, my good friend in Oxford, who's one of the grandfathers of CBT in this country, has said, CBT's a family of conditions, but we're not dissecting them out properly. We don't really know which elements are good for what condition yet. So the problem was looking at other things caused a bit of a dilemma for a committee that quite frankly contained almost all CBT therapists. One of the interesting things in the 2005 and 15 reviews was that interpersonal psychotherapy, which is hardly practiced in this country and very much by the way represents a kind of fusion that Wambold was interested in developed at Yale, operated through adult depression only, Jerry Clermont, Myrna Weissman, and a man called Jean Paquel, who came over back to England and eventually to Cambridge, ⁓ worked on this. And it was a brief intervention, not as brief as we really mean, could be 52 weeks worth, but it was very relational, it was very problem solving, and it went down well in America, but it didn't travel, as Peter Fonagy said, it didn't travel well over to Britain or many other places. So that got into the nice guidelines, because there were six studies, and a psychologist called Laura Muffson was at the forefront, with Myrna Weissman at her back, showing that interpersonal psychotherapy is quite good in schools, and quite good in community mental health clinics, not so hot in the child psychiatry clinics. So that got into the guidelines. And there was a very good review by a good clinical psych- well I'll say she was good, she was here so I better be careful, a Cambridge based clinical psychologist who now is an Australian and very famous who said that ⁓ it is a bit tough because 90 % of the studies that were being reviewed by its scientists were CBT versus nothing and 10 % of the studies were being reviewed was any other psychotherapy versus nothing. what happened if you took up the cudgel and said, how much better is a form of CBT than say psychoanalytic psychotherapy? And that has not been done. And that's why what we were suggesting caught a bit of attention. We didn't know. But there was a very small group of studies from America, again, and Europe, and that has suggested there was a signal in psychomaniac psychotherapy for young people. And finally, the last thing was family therapy. Now unfortunately, the studies on family therapy were quite good and they weren't getting much of a signal at all. So when the NICE guidelines came up for review 2015 again in 2019. I don't think family therapy was going to do very well and it kind of people wanted to acknowledge that it must be important because how can you be in a subject involving child and adolescents and not be in a subject that involves family and it seemed philosophically a problem to say ah well involving the family can't be right but direct family therapy so far has not done very well. So we ended up not choosing family therapy and we argued why. We ended up not choosing interpersonal therapy, which wasn't difficult because there weren't any in this country. And so we had our two main therapies, psychoanalytic, CBT, and our reference treatment, which was termed BPI, because we hypothesized that both the specialty therapists, unlike Wampold's assertion, would be better than the reference treatment. So we had a hypothesis that proposed there were although we didn't explicitly state this, there were special mechanisms in psycho-energistic psychotherapy and CBT that were distinct from what was going on in BPI and therefore they should get a better signal in outcome than BPI did how we set things up ⁓ and that's how we got to where we got to Umar as far as that the study design was concerned.
Prof. Umar Toseeb: You've set that up really nicely. So what did you find when you compared the three?
Prof. Ian Goodyer: Well, so I'll tell you, but first of all, let's get the context right, since we mentioned that. Our study is about people who get to charge their lesson in mental health services. We've become very, very community oriented in the last 10 years. This study was conceived in 2009, eight, nine, and started in about 2010, nine, 10. The paper was published in 2017. That took two years to get into the Lancet. So that's the kind of time scale, the context of time. And the context of the environment that we worked in was we stuck with child and adolescent mental health services, the tier three or tertiary stage patients that probably Jane sees at Great Ormond Street that will come to your specialist services in York that I'm aware of in the whole York area. And we're coming into Cambridge and East Anglia and we chose three parts of the country. We had the whole of East Anglia North London and Manchester, Cheshire and a bit of Liverpool. And we had 15 child and adolescent mental health services and we spent an awful lot of time in getting those services to become research sensitive. And then the collection of some 470 patients, of which 465 got into the study and the three arms had roughly equivalent numbers, I think, 155, something like that. And we got about 83% of each arm through to the final stage where the intention to treat analysis was therefore going to be pretty valid. design on what's called the consort diagram, as you will know, we wouldn't have even got off the editor's table. So we were very pleased.
Dr. Jane Gilmour: But I think that's so, it's so impressive though, because having, you know, having just been through some recruitment and so on, it through some, a variety of trusts and each trust is a different country. You know, when we were trying to, to run a systematic program throughout different clinics, that's incredibly impressive. But all I would say at that, you know, I think the idea of having that degree of getting clients through that percentage is really impressive for anybody that hasn't done this sort of work. I'm impressed.
Prof. Ian Goodyer: I mean, as you can imagine, the number of people involved in making sure that those clinics felt happy and so on, we were all over the implementation and as you may know, there is this study called the Stadia study which was published by ⁓ Kapil Sayal and colleagues at Nottingham which is extremely really difficult to read because in their 1240 adolescents that they followed through services they showed literally no effects of service on mental state from the beginning to the end there is no significant difference in and you should you should probably get capital to talk to you about this study it's only just come out so
Dr. Jane Gilmour: Actually one of our podcasting colleagues was lucky enough to speak to Professor Seyal about the study study. So please do check that out. It's from just a few weeks ago.
Prof. Ian Goodyer: So back to the plot, We had good agreement. had leaders. Every clinic had a research champion who was either a clinical psychologist, a mental health nurse, or a psychiatrist. Every champion talked to each other. We had meetings all the time. You can imagine the amount of organization work and it emphasized to me the importance of getting your clinic in good shape and I think it emphasized to me, we might talk about this, that what's trying to be going on in community at the moment, it has the same principles. If you're going to enter into an organization like a school, the assumptions that you can make about all schools doing the same thing are virtually nil. So the idea of not having implementation and delivery for that group strikes me as just silly. So if you go back to the study, we got it set up right, and we had 465 individuals, and we randomized them to the right to each to relatively proportional groups, they got their treatments, we got to the end, we had a 12 months follow up post treatment which most studies, most RCTs don't do because they want to stop at the point of best effect which is always short. So we followed up for 12 months and disproved that hypothesis too. And I was, we were all delighted. I mean, I can't, I can't really if you... If you want to see the 2023 summary paper in the American Academy Journal, it's hard to believe that all those years later, we've had over three books, over 60 papers, people's careers have been made. I don't think anyone's career has been lost. I haven't asked that question. You know, there's professors and consultants and consulting psychologists, all research fellows have all come out of this extraordinary amount of work for which everyone deserves
Prof. Umar Toseeb: You've given us lots of great context there. And I think one of the interesting parts of the study that we're going to talk about is you've taken this network approach. So my understanding of the network approach is that rather than thinking about symptoms of mental health difficulties resulting from a latent factor or an underlying psychopathology, which leads to that we can't measure. So we measure the symptoms, but we assume that something latent there. The network approach suggests that these symptoms of mental health difficulties cause each other. Is that your understanding too?
Prof. Ian Goodyer: I think it's good enough. It's incredibly, when you get into it, it's really a very complicated theoretical framework. And I think maybe the three of us would enjoy spending the rest of the afternoon talking about that. But to try and get across to people a really different way of thinking about mental state dynamics is not the easiest. First of all, think we should get the context, we should say what impact showed was no significant difference between the three treatments. So I think Bruce would have, I expected Bruce to send me a birthday card or something because it's clearly obvious that young people's RCTs were going to show the same thing as general adult RCTs. There were, there's got to be some common mechanisms across these treatments. We don't know what they are. We were proposing this so-called dodo effect where everyone takes part and everyone has a prize, we had some really good critiques. We chose some people I knew would not bow down to this easily and we got some great critique writing from two colleagues from America and one from here. And they said, well, you know, it is a fantastic start, but don't believe you can walk away from this and think you've got the answers. And one of the key issues in not getting the answers is that we were very fortunate, I think, to see that the difference between therapists in our study, they were about, oh, I can't remember, I think it's about 65 different therapists. And the, what's called the interclass coefficient, intra-class coefficient, sorry, between therapists was virtually nil. So that means we're taking out the individual differences that therapists might bring to the treatment and we can truly examine the results as if there's something to do with therapy. What's very interesting about that is that also implies very strongly there are common effects because as Wambold points out in the studies, individual differences can drive huge differences in treatment outcome if you don't get that right. So here we've honed down and diluted any chance of inter-therapist effects giving us perhaps a better chance of arguing there's some common factors. I must say to you both and to anyone listening, of course, when we presented this to ourselves in the group, the two camps, CBT and Psychoanalytic Psychotherapy, were a little bit shaken because I think everyone expected the specialist therapist to do a bit better. And there was quite a few weeks when people were trying to dissect out a bit of signal that suited CBT or suited psychotherapy. Whereas of course I was completely happy because I thought there would be no particular difference. was striking how similar the findings were. And they also showed this curve, which is why the network thing comes important. I'm getting to it people respond very quickly, There is a really rapid improvement. About 30 % of the variance of improvement occurs within 12 weeks. We're following people up 52 weeks. That's remarkable. All of the therapists who all of the therapy manuals predicted twice as much therapy would probably be required as was needed, including BPI. CBT had I think a 24 session or 20 session model surely believed the 12 sessions would be about right. STPP short term cyclone therapy, they wanted a 30 session to 28 to 30 session model. They thought that was about right. And BPI, saw 12 was the maximum, probably eight. Well, we were all wrong. In BPI the median was 6, in CBT the median was 8, 9, 10, depends where you drew the interquartile range cut off, and in STPP it was half, half the therapists, so it was about 12 to 14. So we all got that wrong. And that really made me think too about what were we doing as therapists, as researchers, bringing these notions to an empirical study. Where did we get the idea that you needed to do more? And that's question I don't have an answer to. think it's worth, why do we do that? And that made me, as I've been doing for the past five years, when we're teaching BPI, which we do around the country a bit, ⁓ I wanted to say to people, what do you think when you're learning whatever you're how do you learn to know when you're going to stop? Tell me what are the psychological, the psychosocial, the contextual features that are going to tell me that you know this is the end of treatment and you wouldn't be surprised. Virtually no young therapist has the idea of stopping worked out in their head. So we gave people a little task when we teach BPI, which is you're to do two sessions with your therapist, you're coming back, we were seeing them for supervision every month, and by the second session I want you to tell me how many sessions you think you need and how you know that you're going to stop. And they say, well, I can't do that. I said, yes, you can. You're going to work out from your assessment and your formulations and all the information you've got, the predictors for stopping treatment and not for continuing the treatment. So that's just an aside that I think is terribly important.
Dr. Jane Gilmour: Really interesting, Very, very, you know, for efficiencies, it would be really interesting to look at that.
Prof. Ian Goodyer: especially if there's no difference in outcome, why did we say that? Well, if you follow the curve down, then by 28 weeks, in terms of the outcome measure of symptom reduction, which was trans, symptomatic and diagnostic. So it's depression, it's anxiety, it's obsessionality, it's wellbeing, it's antisocial behaviour. We measured all of those things multi-dimensionally. And when we looked at it, by 28 weeks, there were 90 % of the people were below a quantitative threshold of 50 % reduction in symptoms, there or thereabouts. But the thereabouts was what got the statisticians and me going. It wasn't really. We had a range in which there were still quite a lot of people with symptoms. So we followed them up for 12 months without any treatment. And when we did that, they continued to get better after treatment. So now we don't even need more treatment. What do we need? We need more time. The rehabilitation from treatment, the recovery coefficient or curve from treatment is still going on for 12 months after treatment. Only 16 % of the subjects relapsed towards the levels of symptoms that they had at the time of therapy. That's a low relapse rate by standards. So what happened with treatment was that everyone continued to get better by and large except for the 16%. And by the time we get to 12 months, less than 5 % of this whole cohort has used healthcare or social care services since end of treatment. Now it's said that we're not very good at treatment. John Weiss has done fantastic work in showing that the real effect sizes, particularly in CBT, but not only in CBT, are much lower because we don't take into account the non-specific changes that occur in control groups with sufficient clarity to show that, there is something about CBT, there is something about STPP, there is something about, and everything else, but there's something about time and recovery, and we need to know what that is. And I think that's... begun to be signaled in work such as that done by Jessica Schleider, who used to work with John Weiss, now a big wheel on her own, and the Jessica Schleider equivalent in Britain, is Maria Lodes, who's at University of Bath. And they're trying to figure out how does one session of therapy go? And what Jessica Schleider shows is that psychoeducation or behavioral activation from the CBT programs are as good as each other and they're both better than doing nothing. In one session, they followed up their patients for nine months and they did not get much relapse rate, but they were mild. epidemiologists have pointed out an awful lot of people would have recovered anyway, but Jessica still got an effect size of about one and a half, which given, know, given that they had 2000 people online in the study, I thought was pretty good.
Prof. Umar Toseeb: We had Professor Maria Loades on a few weeks ago. So check that out. We're really spoiling you with lots of relevant content.
Prof. Ian Goodyer: Our problem with a symptom is that a symptom isn't really a symptom. What it is is an extension of a normative construct beyond the population range that we consider to be alright. Everyone gets sad. Everyone can feel worthless. Everyone has poor sleep. There isn't anyone. If anyone said to me by the time they got to about 16, you know, I've looked at your symptom list and you know, I don't have any of those things. And I would say, don't be ridiculous. Can you read? Let's just sit down for a minute. know, nobody's like that. We have chosen to work in a field where that kind of moving slide rule, as it were, across normative to non-normative to atypical to abnormal to completely wild, unacceptable psychotic features is all on a continuum. Hence the latency concept, that's why epidemiologists in the 60s and 70s thought latent approaches would be reasonable because these are quantitative trait changes. But we call them symptoms because we've got a descriptive categorical term with a lot of holes in it. Now in the model of symptom counts, the assumption is that every symptom has an independent effect. So if you've got five symptoms and therefore get a diagnosis of depression, it's because it's assumed, not that even a lot of scientists will quite appreciate this, it's assumed that each of those symptoms not only has an independent effect, but they're equivalent. Because you don't have to count mood as being twice as important as poor sleep. They're just important as opposed to not. So you reach the end of the distribution threshold where it's no longer normal and you're counted as one unit of thing. Five of those you're depressed. However, ⁓ when we were working on this, it struck us all the time that none of us knew what the common elements in the symptoms were and what the specifics were. So that's when my group at the university, where I was by then, I was at the University of Toronto and as well as Cambridge and the University of Toronto group very good at statistics, And the person who's the first author on the paper we're talking about, Madison, we talked together and she's a clinical psychologist now, director of training at York University Toronto. And she said, I'm quite interested in this. I said, great, I've got an idea, but I don't have the technical skills anymore because I'm getting old and can't remember the name, whether what's left or right anymore. So we got together and she did something called a bi-factor analysis. We wanted to see if we took out the common element, did we have anything left? Because if Wambold was correct and everything's common and it's all latent and all these things look independent, but actually they're not because at the level of latency they all count, then that's it. We don't have to do anything else. Well, that wasn't true, of course. So common bi-factor variance accounted for about 60 percent but there we were, it was published in the JCPP, there were very very clear signs that there might be some precision in treatments but we don't know what they are if we look at the more specific factors that were left from the bifactor variable. The big argument, you may know Jane, you may know that specific factors are just redundant noise I don't believe that and we don't we don't believe that so we published this paper amid some statistical criticism as you can imagine and we showed there must be some specifics so now we have the theoretical dilemma because we've said there is a common feature like Wambold says but we've also got specifics what are we going to do with those how can we so that was when I started thinking there's this new guy this new paper came out in something called world psychiatry and in that paper a very very thoughtful theoretical psychologist called Danny Boorspoon at Amsterdam University. Anyway, he and together with his mathematical psychology friends started to look at something quite old. There's nothing new about network analysis. It's quite an ancient ⁓ theory and quite an important use in big subjects like sociology and psychometric work in large number, even in large number of things like biology. So, I got excited but worried because what Danny was suggesting is what you said, Umar. We think that psychopathology is about adding up atypical, abnormal, severe levels of symptoms that derive from normative behaviors, thoughts, and sensations. But what if it isn't? What if it's actually, what if psychopathology doesn't exist except when things go wrong in the mind that involve those features of the mind, thoughts, feelings, and behaviors, influencing each other in ways that they shouldn't? Now, the idea that one thing leads to another is hardly new in behavioral science. But the idea that one thing has some latent mechanism, have to use the word, that is self-sufficient strength to cause another symptom or another item to turn rogue in the mind, that is both alarming and exciting. So for example, we might now start to think that you can't get to five symptoms to make a diagnosis unless you absolutely have to have an interaction between two symptoms because there is a functional relationship between different compartments and those compartments are doing things they should not be doing in the normal mind. And that's what really got me going about it. To the extent that I wrote a theoretical paper that was chucked out because it was thought disorder. Like I couldn't actually create the right theoretical space to say the things that I wanted to say. So I haven't done that.
Dr. Jane Gilmour: But I so disquieting, you know, have the sense that this is sort of, it feels a bit liminal because it's about to explode all over the diagnostic and therapeutic world. I think it has huge implications and that's one of the reasons why this paper is so thought provoking.
Prof. Ian Goodyer: Yes. Yes. Yes, I agree. Well, it's very kind of you to say that because you won't be surprised to know we had an awful time trying to get it published. ⁓ And the reason for that is precisely because it goes against the orthodoxy, in my view. This paper was reviewed seven times by statisticians, by different statisticians. And I'll tell you why. What's important about the paper is not doing the network analysis. Almost all network analytic papers are cross-sectional. And that's a problem, isn't it? If you're going to start talking about prediction and change and so on. There are two elements in the network announced in network theory that's terribly important for us or for me. One is if it's true that symptom X is good enough to predict symptom Y, then it can only do so over time. You cannot you cannot avoid a temporal feature. So you need longitudinal data. We had longitudinal data because in the IMPACT trial there were five time points. We're obviously going to have trouble over time because we didn't design it to have lots and lots of time points, which is what you really need to show trajectories over time we had five and in theory it's the minimum of three that you need to do anything useful. So we had a longitudinal network analysis design and then it turns out there is no longitudinal network analysis statistic. So in when we first got there and we talked to Danny Busbohm and others in the group at Amsterdam and at Leiden, nobody had yet worked out how were we going to actually analyze data over time? If you wanted to show the interaction between two items at time zero, we're going to predict a new phenomenon, not the same phenomenon, a new phenomenon at time y at a temporal distance between the two points. It didn't exist. So we got someone to work on it. We had a, we have a person in Cambridge who's also worked with us for a long time called Sharon Neufeld, who's a statistical psychologist And she is now a Wellcome Trust senior fellow pursuing these things. And we had Madison, who is very, very competent statistically and mathematically. You have me chugging away in the background. And we had a Dutch advisor who was in fact a mathematical psychologist. And between us, having changed a few of the algorithms and knocked around a bit with the software, we came up with a longitudinal model that allowed variance and invariance estimates. And that meant you could follow things over time. And it wasn't just going to be an effective time, we hoped. It was going to be something meaningful. So that's how we got to the longitudinal dynamic network model, which is now published. I don't mean our data. The model is now published. Anyone who wants to do longitudinal network analysis will now find stuff out there. And I'm sure it's... going to get better. There is an issue with sample size because network analysis is intensive and we just make it. And that's the other reason, it took a while to publish. The JCPP were very interested in publishing it and thanks to them, they stuck with us because one or two other journals gave up, as it were. And we got through and it is what it is. And it is remarkable in its provocative findings and thank you Jane for your comments. So the thing about it is that, which I really like, is the intuitions that we all wrote down on a piece of paper, put in an envelope and shoved them in the drawer, none of them were correct. The findings that we got were not what we expected and that really, and it made us, ⁓ and it came up against our own belief systems. It really did. It took us two years to... get this paper written. It took us another year to get it published. I mean, get even close to being published. And it took us that time because it showed that the most important symptoms at the beginning of the study, these are the 465 depressed adolescents randomized into these three treatments, but now being treated as a cohort, where treatment is now a co-variable, co-factor. The most important features were fatigue and insomnia and that nobody, none of us wrote that down. We all had psychological features as the prime driver and it's not true. And that's about the most robust finding that I want to get across, it's not true. In moderate to severe depression, the driver for the network relationships between items is fatigue and insomnia. Now you say, okay, but not alone. It's there, that's...
Prof. Ian Goodyer: Jane, you're so right. That's why you've got to keep reminding yourself. They're important because of their interrelationship at time one for predicting what happens at time two. And that is a shift in the way we think about things. It should be a shift eventually in practice because the way we assess people should be not just, yeah, tick fatigue, tick insomnia, tick worthlessness, tick mood disorder, tick self-harm. No. What are these things doing? Can we find new ways of doing clinical interviews to say, do you think in some way that not sleeping well or sleeping more, could be hyper or hypo? And feeling tired are connected. Now, it's a really difficult thing to go to the subjectivity, isn't it? mean, asking the patients that is in itself a real problem, but it's not been done. So I think we should do it, although I recognize the difficulty of getting people to try and describe their mental state. So I think And if you notice in the picture,
Dr. Jane Gilmour: I was just going to say that, I am so struck by the idea, as you said, none of these, these, these great minds were predicting what may or may not be influential. And in fact, one of the key findings was fatigue. And, you know, I was mindful of the Shakespeare, I think it was Hamlet wasn't it, who said that sleep is the balm of hurt minds. So perhaps he was way ahead it was all.
Prof. Ian Goodyer: It is. But you're absolutely right. And that means that there's a modular thing that comes here. What is what is fatigue? Because, know, we don't know. mean, the study of fatigue has has never really taken off. And that's there are lots of reasons for that. I think the study of sleep has taken off. But I don't think we've translated it yet into our kind of subject. What does it mean? How do we get to... And again, Umar might remember, I was quite preoccupied with HPA axis research for quite some time. And what I now realize is that we had a correlation between the loss of diurnal rhythm in the HPA axis control center and the presence of insomnia. And I never did anything with it because I didn't make any sufficient theoretical connections you know, can I have 30 years back please? Because that would... I would say, right, you know, where are the young folks? Let's do that. To finish off, you've got to also understand that networks are dynamic and they change over time. So that means you have to understand what are the influential symptoms. And in the paper, we show how influential fatigue and insomnia are.
Prof. Ian Goodyer: But we also show how uninfluential symptoms we often think might be influential are not. Poor concentration is very important, but it does not produce new networks over time by itself. It does not. And social cognition, I don't see much network work in the early stages of depression, but my word, by the end, The biggest observable network is between the things that become important for CBT. The cognitive triad, worthlessness, the future, myself, these are become, these have emerged. So I'm going to make a prediction that might or not be true. I'm not sure that the cognitive vulnerability hypothesis is a primary hypothesis. I think that adult depression emerges from individuals who've had episodes of mood disorder in younger years and they have, as it were, developed their social cognitive triad, which I believe, certainly do believe, and studied it enough myself, I believe, but I think it's not as primary as people thought.
Dr. Jane Gilmour: There's so much controversy and so much to do and so little time. What an extraordinarily thought provoking conversation Ian is exactly what we hoped we would get from you from such an expert. It really is ⁓ something that has got us thinking very differently, reviewing our academic and our clinical work in lots of different ways or at least asking questions and that's the best position to put us all in.
Prof. Umar Toseeb: Yeah, absolutely. It took me back to what 2012 when we used to work together where actually these are the conversations that were the most helpful. Like you think of postdoctoral training as the formal things that you do that are your job, which is data analysis or whatever it might be. But actually these conversations are also part of that experience. And I hope that what we've had today is our listeners also benefiting from that because it's been absolutely fantastic.
Prof. Ian Goodyer: Well, thank you very much.
Dr. Jane Gilmour: Thank you so much.
Prof. Ian Goodyer: It's been a real pleasure. Thank you ever so much for being interested in the paper and inviting me to do this.
Dr. Jane Gilmour: Thank you.
Prof. Umar Toseeb: Thank you. And so that was a very, very fascinating conversation. I think what I really liked was when you start like a podcast or you start any conversation, you have a view of how it's going to go and you start off with a structure. But actually, when you have someone like Ian, and I think that it really demonstrates when you have giants of the field, like they just have so much knowledge that you're just like, okay, I just want to listen now, like, because this is all very relevant. And what it made me think about was when you're new to research, you do some research and it's at like one level. And then as you progress through your career, there are like layers underneath your thinking. the paper that Ian has just described, when I saw it, I was like, why didn't I think of that? Like, that's a really good idea. I have the technical skillset, I could have done it. But actually, he's done that paper.
Dr. Jane Gilmour: Damn it.
Prof. Umar Toseeb: And underneath what's written in that paper, there's layers and layers and layers of like theory, thinking, experience, knowledge, and it comes together in that paper. And if you just read the paper, you think, ⁓ yeah, yeah, yeah, this is cool. This is very nice. This is challenging. This is thought provoking, whatever. But actually having that conversation with him, you realize how much thought, experience and knowledge and how many years of progress, decades even has gone into that paper to get to that point.
Dr. Jane Gilmour: I think that's such an important point to make because it's not just the paper that's written and you can only write that paper if you've been through a variety of different experiences, asked questions, had a hypothesis that just didn't work out the way you thought it was going to and so on and so on. And that depth of thinking and that breadth of thinking was really, really interesting and exciting to hear, to sort of constatine out a thought process over a variety of different experiences and studies. And I hope that everyone else had the sense of that process of thinking that is great to be witness to, isn't it great to be alongside it? It's often those spaces in between that we learn so much from, as you say, just being alongside it is great what I thought was perhaps the most interesting was that theoretical paper that didn't quite, he can't quite talk about not being able to articulate it just yet because it could be so, you know, it's turning the table over in so many ways in mental health ⁓ services and mental health theoretical approaches. And so it almost feels too big. But it feels, as I said, it's liminal. It feels like it's coming into consciousness and coming into articulation. And it will be very interesting period of time, as there's so many levels of need and service provision and so on. Does it need a radical rethink? Probably it does anyway. Could the theoretical position change the rethink in a different direction? Possibly. And that would be very interesting, it?
Prof. Umar Toseeb: I can definitely relate to what he was saying about the theoretical bit because there's like, I mean he mentioned the problem with diagnoses and he was like, let's not get into that, but actually we're going to get into that in a few weeks.
Dr. Jane Gilmour: I know I did cross my mind. That could be
Prof. Umar Toseeb: And I think that for me, that they're not being able to compose your theoretical position into like a coherent argument is very real for me because I've been thinking about diagnostic labels and all those things and I've not quite been able to articulate it well. And every time I try and write it, I'm like, oh, I don't know. And then about two days ago, I just woke up and it just occurred to me and I was like, you know what, I'm just going to write this down. And I wrote it down and I was like, yes, that articulates my position very well and actually maybe Ian will have that moment like maybe it's just when you're consciously trying to do it there's a block and it will just come to him.
Dr. Jane Gilmour: The power of sleep is interesting you woke up and there it was. Which is, and I actually want to just very briefly, although I think that, I think the theoretical and academic ⁓ repercussions are somewhat more powerful in some ways, but I also just want to just, just underline the importance of one of the findings about the potential power of fatigue and insomnia and how addressing that clinically may have a differential impact on lots of young people. So just to highlight from a clinical point of view, that there are a variety of evidence-based sleep programs and sleep, ⁓ usually using a cognitive behavioral model, somewhat emerging literature, looking at a mindful cognitive behavioral module, looking at increasing both the quality of sleep and the length of time asleep for young people and adolescents in particular, because of course we know adolescents are more likely to have depression and they're proportionally more likely to be vulnerable to sleep problems too. Some of those are physiological in terms of having high emotionality and a slight delay in sleep hormone, which means they're sleepier later, but they have to get up at the same time as the rest of the world and some is environmental you know, just having a phone in the room, even if it's switched off as an impact on sleep. those, you know, those changes right there, you know, very small changes, but again, there's an evidence base to think about sleep as a really important part of your treatment plan, potentially with a young person who's showing features of depression will be very important. So for lots of reasons, theoretical and clinical repercussions are quite...quite profound I think in that paper.
Prof. Umar Toseeb: Yeah. And I think the sleep finding is particularly interesting because in my department, there's a whole group of people who do research on sleep and a lot of the stuff that they used to do was sleep and cognition. But I think that in recent years, they've shifted that focus to sleep and mental health. You know, this paper demonstrates in the conversation with Ian demonstrates that quite the central role of sleep here in children, young people's mental health. So I'm hoping that through that body of work in my department, there will be some exciting findings around sleep because they are excellent sleep researchers and now have excellent mental health researchers and it just seems like the right recipe for some success in that area of some advancements. But it's interesting about fatigue. Are funders interested in this? Is a motivation or a need, sorry, not what's the word, motivation and oomph to move that forward.
Dr. Jane Gilmour: Well, I'm not the right person to ask, but it's a question that should be asked because clearly it's not just about insomnia. It's also the idea of fatigue and what that implies and how that can be addressed. It's very interesting. ⁓ so much to do, Umar. So little time. What's your academic takeaway, do you think?
Prof. Umar Toseeb: My academic takeaway, I don't, I think like it is that what I said just after Ian left, which is you can do the same, like answer the same research questions and on paper, it looks like a study that you could do and that somebody else could do, but what the thought process behind it and the theoretical underpinnings and the layers and layers and layers of knowledge that has gone into that is not always apparent and and the second takeaway and actually I've just thought of this is Ian seems to be reasonably well actually he said network modeling was an ancient approach but like he seems this seems to be the first time he's applied it in his research and I've applied it recently in my work too. It's interesting how two people who have come to this method recently have very varying levels of understandings of what it means and how they explain it differently. So the way I explain it to people is not how Ian explained it to us, but they're both correct and they are both making sense, but it's just indicative of where we've come from and what our levels of experience and knowledge are in the field.
Dr. Jane Gilmour: And I wonder if it's significant that both of you have come to network approaches at the same time as there's something in the Zikaist. But again, a different question for another time. From a clinical takeaway point of view, I would say it's about the zoom out. First of all, thinking about these wider psychotherapy debates. And we might need to, and I suggest that we should revisit these age old questions in the case of depression. Certainly, you know, when we ask what works for whom and why. In terms of zooming in from our clinical takeaway, consider sleep and fatigue as an important priority area of investigation with young people who have features of depression.
Prof. Umar Toseeb: Next week we'll be joined by Divyangana and Gaurav Rakesh about poverty and child and adolescent mental health. Lots of thought provoking discussions about the times we live in and it's a fantastic episode. So please tune in. Don't forget to subscribe, like and share with your friends and colleagues.