The EABCT congress in Athens 3-5 September 2020 – Report from the second day
On the second day of the European Society of Behavioral and Cognitive Therapies (EABCT) congress, which took place online in Athens from 3 to 5 September, I attended the presentations by Anke Ehlers of the University of Oxford on post traumatic stress disorder (PTSD ) and Janet Treasure of King’s College London on anorexia nervosa.
Two of the most significant ideas presented by Ehlers, with empirical solidity: she reaffirmed – given in hand – the superiority of cognitive behavioral therapy (CBT) for PTSD over any other therapy, including Eye Movement Desensitization and Reprocessing (EMDR), and he illustrated the new hypotheses on the real mechanism of action of CBT in trauma, hypotheses linked to parallel discoveries on the pathological mechanism of PTSD.
Reaffirming the superiority of CBT is not only the result of a mere rivalry between psychotherapies – CBT and EMDR – but it is also the effort to provide patients with reliable guidelines on the most specific treatments for PTSD. As we know, in recent years EMDR has legitimately advanced its candidacy for specific and choice therapy for PTSD and many other trauma-related disorders. The merit of this challenge to CBT, which held this privilege, is to have generated a healthy clinical rivalry on the effectiveness of treatments that benefits patient care.
The efficacy data brought by Ehlers show that both psychotherapies of choice, CBT and EMDR, are much more effective than any other psychotherapy in terms of effect size and various other statistical measures (of which I ignore the arcane technical secrets) and that CBT shows a margin of superiority over EMDR. Hence CBT and EMDR are recommended by far for PTSD over any other therapy, and significant preference is given to CBT. It is an important conclusion in times when Dodo’s verdict, reliable for other cases (for example personality disorders), however, if abused, risks favoring a stagnant scientific and clinical picture in which everything done in the patient’s company a room more or less works.
Alongside this significant result in favor of CBT but in some ways not new but just a little forgotten, Ehlers also offered innovative results, also empirically supported, on the functioning of CBT. In this case, too, credit must be given to the rivalry with EMDR: it has stimulated more in-depth research on the psychopathological mechanism of PTSD and on the process of action of CBT. The clinical model of PTSD proposed by Ehlers is more procedural and metacognitive than the classical one of the CBT group of Oxford (a group to which Ehlers also belongs fully). It is true that the clinical nature of PTSD favored a procedural gaze already in the classic CBT model: post-traumatic malaise did not depend on distorted assessments of reality but on a dysfunctional management of intrusive traumatic memories.
This processual and metacognitive insight already present in classical CBT was further developed by Ehlers who studied in depth the intrusive mechanism of traumatic memories in PTSD, demonstrating how they present themselves to consciousness with the immediacy of a real experience and without their own. character of past memories, so that the patient who experiences them attributes to them a real and immediate threat value. The memory of the episodes of danger is totally disjointed (if you like, dissociated) from all other memories and for this reason it loses its quality of memory. The therapeutic consequence is a metacognitive and normalizing work of construction – tiring and not spontaneous – of the awareness of the memories character of these traumatic memories. Tiring construction,
In this way a whole series of past hypotheses on PTSD based on the exploration of traumatic episodes such as an excavation and reconstruction of forgotten or even removed information turns into its opposite: memories are not removed at all but are all too well present and immediate to the patient’s mind. But this is not the usual critique of psychoanalysis; it is also a question of re-dimensioning the conception of certain imaginative interventions in fashion today as a vivid and intense reinterpretation of a past that conditions because it is semi-forgotten. On the contrary, it is about revisiting the past in a state of emotional detachment that makes them less vivid, less immediately imagined and not at all relived with intensity. Instead it is the critical and rational detachment that favors the awareness that we are dealing with memories and not present experiences. A metacognitive work and, in a certain sense, anti-experiential if with this term we mean a direct contact with the emotionality of the present moment. If anything, it is a question of a metacognitive, mediated and not immediate experience. And both CBT and EMDR at their best seem to be working in this direction.
The CBT interventions recommended by Ehlers are called “updating trauma memories” and “discriminating triggers of reexperiencing (THEN and NOW)” and consist in a work of reconnecting traumatic memories with the past context from which they have separated and of recognizing the stimuli of the present that they trigger intrusions in an unpredictable way for the patient (even if then there are often unconscious associations by analogy). Basically conscious and reflective work, based on a strong sharing of the formulation of the PTSD model that favors a rational management (let’s face it) of unpleasant mental states and not on a release from intrusive memories after some corrective emotional experience.
I dedicate fewer lines to Treasure’s keynote on anorexia because it was a presentation that was largely psychiatric rather than cognitive behavioral, with a lot of data on risk factors.
However, the data on the cognitive and interpersonal aspects of anorexia are interesting, empirically confirmed (which is a great merit) although not new: the criticistic trait, covertly conflictual and overprotective of the anorexic’s family relationships, which favors an avoidant attitude in patients and little inclined to personal growth and exploration and that takes refuge in a singularly restricted perfectionism, limited to the control of body weight and appearance.