In this episode, Rachel talks with Professor Barney Dunn, clinical psychologist and researcher at the University of Exeter, about his work on Augmented Depression Therapy (ADepT) a novel approach to treating depression that targets anhedonia (difficulty experiencing pleasure) and aims to boost wellbeing.

Barney shares personal and professional insights into why and how traditional CBT might be augmented to actively help people rediscover joy and meaning in life. He explains how ADepT, based on systematic research, integrates cognitive behavioural principles with techniques from ACT, mindfulness, strengths-based CBT and more, all aimed at helping clients live well alongside depression rather than simply reduce symptoms.

Whether you’re a therapist working with depression or simply curious about new directions in CBT, this episode offers a thought-provoking and inspiring conversation about what it really means to get better- and stay better.

Resources & Further Learning:

Find more information about Barney and his publications here

Find out more about ADepT here

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If you enjoyed this episode, check out our sister podcasts, Let’s Talk About CBT and Let’s Talk About CBT – Research Matters for more discussions on evidence-based therapy.

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

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This podcast was edited by Steph Curnow

Transcript:

Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients.

Today, we're joined by Barney Dunn, a highly renowned research and clinical psychologist specialising in therapies to improve wellbeing and functioning in depression and related mental health conditions.

Professor Dunn is based at the University of Exeter, and he has a finger in many interesting pies, but today he's here to talk particularly about his work developing and implementing treatment for depression with a particular focus on symptoms of anhedonia. Thanks so much for joining us, Barney.

Barney: Thank you very much for having me, delighted to be here.

Rachel: And just as a starter, we want to think about how you got into this area of research. And as I said, you're interested in lots of different things, but you've devoted a lot of your time and effort to thinking about anhedonia. There's so much to fascinate in clinical psychology. I wonder what got you interested in the field of depression and specifically this anhedonia area personally and professionally?

Barney: Professionally, when I was doing clinical training and learning to cut my teeth with a lot of depression cases, hitting a point where I felt like I'd done quite a lot of work reducing the negative and reducing symptoms, but the job was only half done. And clients were saying things like, at the end of therapy, well, I'm not depressed anymore, but I'm still not quite sure what life's for and I'm not enjoying stuff. And I felt...Well, maybe I'm not doing CBT correctly, or maybe there's a bit of a trick missing about how we can do that stuff better. So that was the kind of professional route into it. The personal route into it was a bit more growing up with my dad. So I lost my mum when I was little and was very well supported by my family but seeing my dad in my eyes never quite get back to life, never rediscovering joy and connection and meaning and grinding through and turning the wheels, but not getting pleasure back and thinking there's a missed opportunity there. Even after the difficult, there's possibility for the good. And so that's the kind of personal motivation is thinking of clients like my dad, how could I help them get back to life when they've been through some difficulty and rediscover wellbeing and joy?

Rachel So that really meaningful connection for you from your own lived experience with being alongside someone who never got that meaning back. Those are big questions. And I hear what you say, you working in depression, you get good results with your clients in terms of their symptoms improving, but you talked about a job half well done or half done. Currently, how well are these symptoms targeted in mainstream treatments? I mean, it's a brave man who takes on, you know, Beckian cognitive therapy and thinks, right, we need to do better.

Barney: Well, I mean, we should follow the data. So if you do Beckian cognitive therapy and indeed any other evidence-based treatment for depression under ideal circumstances, really good therapists who are really well supervised, you basically get about 60 % of clients who will meet diagnostic remission at the end, half of whom will relapse within the next two years. So that's ultimately a 30 % proper response rate. And that means we leave a lot of people with a lot of distress afterwards, you know, 70 % of the people that are coming through our doors. If you look at NHS Talking Therapies reliable recovery rates for depression lag a bit behind anxiety recovery rates, and they're a bit below 40%. So more than 60 % of the folks coming through NHS Talking Therapies with depression will be depressed again within a couple of years. So there's definitely still a problem to solve and it feels like a really interesting and clinically important question to work on but one to be humble about because lots of really great minds and really hardworking people have thrown themselves at it, and what we've done is proliferated a lot of equally partially effective treatments but we haven't made any stepwise gains since Beck who did make that massive stepwise improvement in the late 70s.

Rachel: Yeah. So it's great that there's evidence-based treatments are out there, but there's still a lot of people that find that there's something lacking at the end of therapy or even don't improve. So if we treat the sort of negative feelings, so there's negative symptoms of depression. Doesn't that automatically also address some of this anhedonia or positive valence system? And if not, why not?

Barney:  So I think that's the assumption we all came from to start with, which is there's a continuum of affects, which you go from being really negative, you get to this middle point where you've been meh, and then you move to this position where you're feeling really positive. So if you bring down the negative, the positive will inevitably increase. But then there's been some interesting other ways of thinking about that and recognising that they're at least partially dissociable systems, which means positive affect can move when negative affect doesn't move and vice versa. And again, just to come back to my dad as a case example, when my dad was dying of cancer, there was a lot of distress and difficulty and pain. And there wasn't a way to make that go away. He was dying of cancer, but that didn't mean there weren't things we could do to find wellbeing within the midst of that. One of my favourite memories with my dad in the last few months was he wanted to drive his car again, but he was on too much morphine to drive safely. So we put him on the sit on mower and drove around the garden, kind of destroying my mum's prized flower beds and my stepmother's prized flower beds. And that's one of my favourite memories, like chuckling with my dad on morphine, driving badly around the garden, amongst a whole lot of negative affect. So I think it's quite useful to realise even in the midst of depression, you can find joy and pleasure.

There's also an increasing basic science argument here, which is the systems of the mind and brain that regulate negative emotions and avoidance of threat are partially dissociable from the systems of mind and brain that regulate positive emotions and approach towards things. So you can move one without moving the other. And my view is you need to do both in therapy. Bring down the negative, push up the positive.

Rachel: Does everyone experience, I mean, you've just spoken about an example of your dad experiencing lots of negative emotion, but still having that positive emotion. Does anhedonia develop for some people and not others in the context of depression?

Barney: I think it's like most ways of thinking about depression, things fall on a continuum. Estimates of how many clients have clinically significant anhedonia ranges from 30 % of them having really severe and profound anhedonia to 70 % having significant anhedonia. It's one of the, along with elevated negative affect, it's one of the two cardinal symptoms you need to get a diagnosis of depression. So it's pretty prevalent, but it isn't there for everyone. And it isn't there for the people that have it all of the time. Its just sometimes people need to develop the skillset when anhedonia is with me, how can I step away from it and get back to wellbeing and joy?

Rachel: And is there a differential pathway? I mean, will it be some people who are more likely to develop anhedonia than others or circumstances that are likely to lead to that? Or as you say, is it just likely to be there or not at different times than that pathway?

Barney: Well, so my view again is like most symptoms, there are many ways into it and many ways out of it. So it's dangerous to put hard and fast generalisations onto it. But I would say there definitely is a kind of genetic, biological basis for your reward system to be more or less reactive for better or for worse. So some people are just born with a capacity that reward washes over them and they really enjoy it. Others have to work a bit harder. I'm increasingly struck that in people's developmental histories, an absence of early positive experiences then makes it hard to understand and be able to lean into positive emotions. I love the move towards trauma-informed practice, but I think we also need to have just as much focus on clients who've missed the positive and how we can grow that system later from scratch when it wasn't developed during childhood. There is also a pathway from chronic exposure and stress and trauma that alters the reward system. So I'd say there are those three groups of biological predisposition to anhedonia, people through complex trauma have kind of what we'd call neuroendocrine scarring, the kind of hormonal and biological systems that regulate, change the positive affect system, and then people who just weren't exposed to reward and didn't learn how to play with it when they growing up.

Rachel: And this for many people is kind of quite a new language and a new way of thinking. Lots of people listening to this podcast will have started their training in CBT, either as CBT therapists or within other professional trainings with the Beckian model of depression and learning their skills. And if we say the words, core beliefs or dysfunctional assumptions, they'll already be mapping out in their minds a longitudinal maintenance formulation.

What would a formulation of depression look like taking into account these systems of positive effect and reward processing these kinds of perspectives? And before you start Barney, I need to make you aware of our Practice Matters podcast challenge. So we like a good formulation, but there can be no boxes or arrows or other visual aids because we're an audio podcast. So just a brief explanation about how the problem develops and is maintained without repetition, hesitation, deviation, power point, whiteboards or flip charts.

Barney: I like the challenge, Rachel, and you also know me, I'll ignore the rules as we go along slightly. So I'm to give you a narrow formulation of what might get in the way of a client enjoying potentially rewarding experiences. In the therapy ADepT. we've developed, we think about psychological mechanisms of mind that when people are exposed to potential opportunities, get in the way of that leading to sustained and ongoing positive emotions.

The first thing is behaviour avoidance, people don't put themselves in situations that are potentially rewarding. The second thing is behavioural shaping. So they're not choosing activities and refining activities in the best way they have to land. So if I'm going to a party, arriving with friends and making sure the music I like is playing. The third one is intentional. When they're in a potentially rewarding situation, they're noticing the bits they don't like rather than the bits they do like. So maybe I'm out for a beautiful meal but don't like peas, so I focus excessively on the peas on my plate, not the beautiful prawns I really like.

Rachel: My kids need this. I'm just saying.

Barney: The fourth one's kind of cognitive. So what we're realising is a lot of clients who are depressed have a set of appraisals when positive emotions start to switch on that dampen them or crush them. It's because they're a bit alien and scary and weird and uncomfortable. And the appraisals are things like, this is too good to last, I don't deserve this, people will think I'm too big to my boots. So what those kind of appraisals do is they instantly extinguish the positive emotion. And it's a bit like a candle snuffer in a church. The flame is instantly squashed. And what you're left with is the smouldering flame that isn't very pleasant afterwards. There's also a nature of how experientially engaged in the positive activity people are. Are they being very heady and evaluative? A bit like Barney going to a party and wall flowering at the edge and not really being part of it, watching it, versus Barney going to a party and really connecting to the sensory experience. So in ADepT, what we're doing is we're spotting all of those patterns that get in the way of positive affect, triggering and sustaining, and we're getting clients to take a step in the opposite direction. So when they want to avoid, we get them to approach. When they're focusing on the negative, we give them skills to focus on the positive. When we're having dampening appraisals, we give them skills to come up with realistic positive appraisals that can help them engage. When they're being very stuck in the head, how can we get them back into the mindful everyday moment and so on.

Rachel: So that was a brilliant summary, Barney. And I know you've talked about high ADepT. You like to keep things short and punchy. So you're obviously well practiced at that. But you've said that there's key factors of behavioural avoidance, behavioural shaping, attentional processes and cognitive processes that are maintaining the model. And you've talked already a little bit about how your treatment focuses on that. Can you tell us a little bit about ADepT? What ADepT stands for and what that means.

Barney: Well, so ADepT stands for Augmented Depression Therapy, which was basically an attempt to get better at treating anhedonia in depression. And the broad formulation model in ADepT goes something like this. We think people get depressed for good reason, usually because life isn't going in the way that they'd want it to. So what we're trying to do is help clients clarify what's important to them and makes them tick. So that's values work. Then we try and behaviourally activate them towards getting more of that stuff in their lives. And we fully expect that when that happens, depression is going to try and trip them up as they go. Life will throw them challenges and depression finds ways to make those small hills turn into mountains. How can we take a step away where clients have resilience to challenges in life? Life also simultaneously throws us opportunities and depression is really good at snuffing those out, how can we help clients instead lean into those opportunities? So we're trying to create a virtuous circle where clients clarify and move towards what's important to them and act opposite to their depression so that they get the full potential out of these life situations they're engaging in. And I guess the flip from CBT is actually producing depression isn't the goal here. By the time most people are coming to see us, certainly for high intensity CBT, they're usually on their third or fourth or fifth or sixth episode, if you look at the epidemiology of depression, we know it is a kindling condition that people are likely to have an ongoing vulnerability for. And in some ways it's an unrealistically optimistic model to say, I can cure you, I can get rid of this thing. In ADepT, we're instead saying, how can we support you to live well alongside your depression so that you can have wellbeing? And by wellbeing, we mean getting meaning, getting pleasure, getting social connection. And we frame depression as a barrier to achieving those goals. And we say to people, there'll be times in life when you are in a depressed episode, how can we help you get as much wellbeing at those times as you can? There'll also be times when you're not in a depressed episode, how can we really help you lean into wellbeing at those times? So it's ultimately learning to live well alongside depression, befriending the naughty black dog that's tripping you up and trying to turn it into a bit more of friendly house pet that you trust in your living room.

Rachel:  And I was struck by what you said at the top of the podcast around, you know, patients getting to the end of treatment for depression and maybe feeling less low, but saying, actually, this hasn't addressed this huge important aspect to me of where's the meaning in my life and where's the positivity at the front end of treatment when you're engaging them in this idea of, of not maybe targeting the depression or, or the goal not being to be depression free but rather one of wellbeing. How do folk engage with that?

Barney: I mean, this was one of the really interesting empirical questions when we talk, because I guess the standard view was you can do this well-being work at the end once you've got people better. And surely it will be profoundly invalidating to say to people right at the start of the work, let's really think about what will make you tick and make you want to get out of bed. And what we've found is the opposite. If you clarify what's important to people and help them move towards it, it often helps give them the motivation to keep pushing through when their depression is saying, all I want to do is lie in bed, stay on the sofa and withdraw. Having that, this is what my mind is telling me now, but what's important to me at a higher order level is I want to be a good father or maybe I want to be a marathon runner or maybe I want to do a good job at work. That can give me enough distal motivation to keep me pushing through the avoidance.

Rachel: It sounds like as in standard cognitive therapy with depression, would expect trip ups, we would expect ups and downs and we might often formulate those in therapy as an opportunity to test things out. It sounds like those are not only formulated as an opportunity to test things out or put strategies into practice, but actually almost quite essential to the ADepT process that people are experiencing those trip ups to be able to kind of implement what they're learning.

Barney:  Yeah, one of the things I found in my early CBT practice was I was thinking, well, these people are struggling to get back to reward. So thinking all I've got to do is give them a massive hit of reward. So they used to like parties, let's throw the best party ever so they can get back there. And people were trying it, and they were finding it really quite aversive and saying, I don't like that anymore. And then I was at a kind of talk by Paul Salkovskis, he was being really entertainingly provocative about how badly we've done in the depression field. They say you depression folk just need to learn from the anxiety folk about how to improve CBT outcomes. So I thought okay, I'm going to do a thought experiment of taking it literally. What happens if we re-conceptualise anhedonia as an anxiety disorder where the phobic stimulus is a fear of the good. What would I do there? Well, I'll do a graded exposure hierarchy where I'd gradually get people back towards rewarding activity in small steps. I'd fully anticipate it's going to be difficult as they re-engage with this stuff. They need to stay in it long enough for the difficulty to pass so that something new can come out at the end. And I'm going to keep really vigilant for safety behaviours that get in the way. So all of those psychological mechanisms I talked about earlier that get in the way of pleasure experience, you can conceptualize them as safety behaviours. We're trying to encourage clients to drop them, take a step in the opposite direction, sit with the initial discomfort of feeling positive. It feels unsafe, it feels weird, it can feel a bit disgusting for some clients who haven't had it for a while. Trust if you stay there long enough, the light starts to come in and feel a bit different. So that's the flip from how I used to do classic CBT behavioural activation. And we're really explicit in that early behavioural activation. What we're trying to understand here is how your depression trips you up. We're not expecting you to enjoy this stuff initially. What we want to understand is how's that depression coming in and snuffing that candle out so it gets blown out instantly. And we just welcome that as an opportunity. Great. We're now understanding how your depression trips you up as there's the chance to do something different with it.

Rachel: So the major thrust of the therapy in all of this is that this thrust towards wellbeing and value and along the way there's going to be ups and downs. But actually those are to be expected and utilised in terms of developing those skills.

Barney: And there will definitely be downs, but there are always ups, even with the most depressed clients. Because where, I'm sure we've all had this, where your depressed client comes in through and say, how's your week been? And they go, nothing's happened. And then you look at their mood diary, and there is always some variability in it. Now as a CBT therapist, I'm really well trained to say great, there's that really difficult, challenging point where they had an argument or they wanted to self-harm or their mood really dropped. And my attention would naturally be drawn there to go, let's understand and formulate and give them a way to step out of it. But what's it like if you do the thought experiment of let's look at those moments where it wasn't that, where it was slightly less low or maybe even good, what was happening there? Can you put an equal amount of your attention or focus on that? So clients learn from the good. And certainly, my experience when working with classic CBT is when negative affect is flooding the room and stuff is feeling really difficult, that's when our minds are really not open to cognitive change. It's like new ideas bounce off people, they're resistant. I found it much easier to actually do the cognitive work with people after a positive exception. So you're looking for those moments where it's been a bit different. You're reactivating them in the room so that positive emotion is switched on a little bit. And we know the evolutionary function of positive emotion is it makes us a bit more creative. It makes us a bit more open to social connection, and it makes us a bit more open to activation. So that's the time when it's easier to do the cognitive work after a positive exception, not in the midst of a negative pattern. So we're doing the cognitive change work in a different place.

Rachel:  And being creative, social and activated sounds like a good place to be. And you've said that ADepT integrates interventions from CBT, ACT, positive CBT, strengths-based CBT, wellbeing therapy, goal setting and planning approaches, behavioural activation, MBCT, future directed therapy, the cognitive behavioural analysis system of psychotherapy and dialectical behavioural therapy, and that it integrates ideas from positive psychology literature. That's a huge and diverse range of approaches. What unifies the approach and makes it not just a sort of bunch of eclectic techniques, because I know that's not the way you work Barney.

Barney: So I sometimes see two traditions of CBT. There's the very, I'd call the UK tradition is a very manualised one where we need to do it in exactly the way trials have shown it works that of following this particular treatment and anything off that is unhelpful therapeutic drift. But actually we need to remember the Beckian origins. Tim Beck was the ultimate theoretical magpie. And the few times I was lucky enough to meet him, he was really clear. It's good CBT if the intervention elements you are choosing match your cognitive case conceptualisation. So in ADepT terms, I'm thinking, what is the valued activity someone's working towards? What's the depressive mechanism of mind that's getting in the way of them dealing with the challenge or taking the opportunity? And therefore, what is the intervention element I want to bring in now that will help them step away from that So if a client is riddled with self-criticism and I want to move them towards self-compassion, I think about how can I weave in some ideas about compassion focused therapy, but in ADepT language where we're doing it with solution focused stuff. If a client's very behaviour avoidant, I'd go back to behavioural activation routes and I would think, okay, what are the ways to activate clients here, break things down into small steps, think about SMART goals and whatever, but I'm doing it in solution focused language. So what orients ADepT as a cohesive therapy is activating people towards values, spotting mechanisms of mind that trip people up and choosing an intervention element that has an evidence base to work on that mechanism.

Rachel: And those mechanisms have been identified through basic science and cognitive science and theories and testing.

Barney: Yeah, and actually, this is me putting a bit of provocative challenge back to the conventional CBT depression crowd. If you actually look at how highly established has been the mechanism for negative Beckian cognitive therapy, it's a little bit mixed. In my world, if something's really going to be a mechanism you should target in therapy, you need to have quite a high evidential bar that you should be working with it. It should be associated with the phenomena of interest and the mechanism should correlate with anhedonia prospectively and longitudinally. When you manipulate it in the lab, so you turn a mechanism on or off, anhedonia should come up or it should come down. When you do a treatment trial, the extent to which you change that mechanism should mediate the extent to which your symptoms improve- and there are very few mechanisms in any aspect of depression research other than what can work on rumination that they've taken all of those evidential steps to show it shouldn't really be a target. So we've been running for 15 years a basic science program that's applying that towards our candidate mechanisms of mind that get in the way of pleasure experience, so dampening appraisals, altered and reduced to positive attentional biases and so on. And when we are convinced something's a mechanism, then we start targeting it in the treatment. That's the kind of basic science roots to it. Very much influenced by David Clark's copy book about how he developed PTSD and social phobia treatments. He wrote a beautiful paper at John Teasdale's Festschrift about how did I actually develop these therapies? And we took that approach to how we've tried to target the positive affect system in ADepT

Rachel: So systematic research. It sounds like both you and Paul Salkovskis like to be productively provocative. So you've given us a really good sense of the overall focus of therapy. How might that translate into what a therapist might actually do in therapy? And I hear what you're saying about you're not necessarily taking a manualised approach in a kind of paint by numbers manner, but what would a good course of therapy typically look like if you can say such a thing?

Barney: Well, so just to be clear, I think where manualised treatments work really well is where you have a very clean and clear phenotype, so a particular clinical presentation walks through your door and you can be fairly certain mechanism X, Y and Z will be there and they need intervention elements, P, Q and R as a result. And that's why I think anxiety for CBT works so well. It's a more homogeneous presentation. If someone comes in with social phobia, you are pretty likely to see these things there. Depression is by definition, much more heterogeneous. It can be any combination of 10 symptoms and there are many different forms of presentation. So if you try and do the same things with everyone, it's going to be trying to squeeze a round peg into a square hole. So ADepT is all about training therapists to be good at that pattern matching.

Rachel: I remember you saying, Barney, to me once when we were talking about exactly this, I was used to working very closely with anxiety disorders and we were talking about treating depression. there's something, something just feels more difficult about it. And I think you described it as the difference between a sniper approach and guerrilla warfare. And that really stuck with me and really helped me in terms of those formulations.

Barney: Yeah, have to, you have to, you know, when you're doing guerrilla warfare, you have to take the opportunity and pop out and do what you can at the right time. So when a mechanism raises its head, that's when you work on it. You can't say in session four, I will always work on dampening appraisals and that will be relevant. You need to look for the opportunity when dampening appraisals are around and then choose to work on them.

So with that in mind, how did we design ADepT? So it's a therapy of three parts. The first eight sessions we described was a bit like doing an A level in wellbeing. It's where we introduce the model and the tools of therapy. We start by giving a rationale about why it might be useful to grow a positive muscle and reconnect to wellbeing and learn to live well alongside depression. Then we do mood diary, like you would in the conventional CBT, but very much more interested in where are the moments of light. Where are the things that slightly lift mood? And we do a lot of solution focused inquiry. And we're just curious about what was it about that, that slightly reduced the darkness or maybe even turned the light on. And then we use that to populate what we call the values dartboard. So we split the world up into roughly four areas, work, hobbies, relationships and self-care. And we're trying to get to what makes clients want to get out of bed in each of those areas and how much of that stuff are they getting? And how can we help them get more of that stuff so that life is, work's going a bit better, relationship's going a bit better, hobbies are going a bit better, and they're looking after themselves as they go. And critically, that clients are getting a balance right between those two areas. So know, maybe Barney's values dart board is a bit too work occupied and I need to shrink that so I have time to go skiing with my kids. So that's kind of sessions two and three is clarifying values. And then we start activating people towards goals consistent with those values. And we say, this is where we really expect depression is going to come in and trip you up. And then we introduce them to a simple mapping tool, bit like Chris Padesky's hot cross bun, but with a few tweaks to understand how depression sometimes trips them up, but also just as well how things sometimes go well and they do something different. The tweaks we're bringing into that hot cross bun are we're taking a utility-based approach. So what is most likely to get you what you want here? So we start with going, what was the activity and the goal? And what were the consequences? Did you get what you wanted? And then we're thinking about patterns of thinking, attending, physiological regulation and behaviour to see, does it help clients achieve that goal? We're also building in a strong emphasis on self-care. So what are you doing first to create the opportunity for this to go as well as it could? And also, we have an environment element. How was the broader world helping or hindering you there? So what we can do is we can map out a depressed me. This is how depression tripped me up. And then we can start to move towards a new me. If I was trying to achieve this goal, what would be most likely to get me those consequences? We use that as a vehicle for loads of behavioural experiments. Like, okay, so maybe you could try a different thought on for size. I don't know if it's accurate or not. Let's see if it's useful. Maybe you could work on a different behaviour. And so I think most CBT therapists are very familiar with negative virtuous circles. We're trying to build here positive virtuous circles. Maybe the idea is if you think in this way, it makes it easier to behave in this way, which is more likely to get you your desired consequences.

So where have got to so far? We've introduced the model, we've clarified values, we've introduced a mapping tool to formulate how depression trips them up. And then what we're also introducing is very systematic techniques to just consolidate positive experiences. We do regular positive journaling at the end of the day. What’s an opportunity taken? What's a challenge met? What did I do that helped? And we also get people to engage in what we call everyday simple pleasures but being experientially engaged and when they do it. So most clients like me, I've already spent £2.50 on a coffee this morning. I barely tasted it because I was prepping for this podcast with Rachel. And what would it be like if I stopped and fully engaged with the sensory experience around it?

Rachel: I'm now feeling responsible for having destroyed your coffee. Barney, I'll buy you another one next time we see each other.

Barney: Or another way to think about it is you've given me this great opportunity that's really values consistent and aligns with my personal meaning system to talk about work I really love. So thank you, Rachel.

So we've introduced these techniques in the first third. Second third is putting them into practice to get clients to, okay, so if work was going to look 20 % better in the next few months, what do we need to change? Hobbies, relationships, and so on.

And then critically, the last third is about how do we then turn this into a habit for life? What I found with classic depression relapse prevention plans is you build them and then clients put them in a file drawer and forget about them because you've got them better. And then six months later they go, what was it I did in that CBT stuff? It helped and they've forgotten. Whereas instead we're saying these are habits for life that if you keep going will sustain your wellbeing and make you less vulnerable to relapse. So using the language of Jon Kabat-Zinn, he talks about mindfulness is like weaving your parachute every day so that when you need it, you can jump out of a plane. But we're not just saying that in terms of, should you have a big mood challenge, you know how to manage it. We're also saying these are the skills you need to live well every day. So it an ongoing habit. And then because a lot of clients told us that the end of therapy feels like a cliff edge. And this is another thing, when you actually think about therapy from the outside, how many other close, caring, supportive relationships would have such a cliff edge ending as we do in classic CBT? Clients said it felt like it was great. I've got on with someone and then I never saw them again. That was so weird. So we offer booster sessions over a year, five flexible sessions that people can use as they see fit to continue with the progress they want.

The structure of therapy is very similar to a CBT session except it's geared to overcome the client and the therapist biases to attend to the negative. So the first question is tell us about something that's gone okay this week, maybe an opportunity that you've taken or a challenge that you've met. So clients know I'm going to have to think of something to talk about. And the review at the end is, you know, what are the two or three things that you found useful in today's session and how are you going to put them into practice? So what we're trying to do is recalibrate the balance of sessions to notice strengths and better things.

Rachel: Amazing. Can I ask about each of those stages a little bit more? So the values work at the start. Sometimes when I speak to clients about values, they look very blank. What's meaningful and valuable for you in life? And I can imagine if you've got a long history of depression, even harder potentially to engage with that. Are there tools you use to help people identify and connect with what's meaningful and valuable to them?

Barney: Well, so I'm a big ACT fan and here's my critique of act. It sometimes feels like a very intellectual exercise, and it seems to lead people towards kind of, you know, apple pie and motherhood as well. This is what I'm supposed to say I like. From ADepT, we're much more trying to go from small positive exceptions that are happening in everyday life to start to explore what was it about that that floated your boat. So let's say a client comes in and goes, it's been a really tough week, but I did at least manage to get my dog out for a walk on the beach. Okay, so. And then we almost do the opposite of the downward arrow that would get you to a negative core belief. We do, this is borrowing language from positive CBT, we do the upward arrow, which is, okay, so you were out with your dog on the beach. What was it about that that floated your boat? Well, I suppose I'd like to be now in nature bit. Okay. So you being out in nature a bit. What is it about being out in nature that matters to you? And you're trying to get to the highest level of abstraction you can and go well, I'm wondering here if we've started to form a hypothesis that one thing that floats your boat is pets, if that's true, how about we test that out as a behavioural experiment? What happens if we get you to do a bit more of that? If that also lifts your mood in the same direction, that's starting to tell us what's important to you. So I sometimes use the language if it's like, maybe you're the kind of kid who's never had the chance to work out what your style is in the clothes you're in. So I'm going to take you to a clothes shop, I'm going to get you to try on loads of different clothes and you're going to walk around with them for a couple of weeks and see which ones feel like you. So we're getting there through behavioural experience, we're not getting there through intellectual abstraction.

Rachel:  So it's from data and experience rather than just this actually quite terrifying blank canvas for some people when they're just asked to say, and maybe there's that pressure to say what you think you should say about meaning and values in your life rather than to really explore it as you say from experience upwards.

Barney: Yeah, so one of the ADepT principles we give for therapists is just go from the informal to the formal. So I think in CBT we quite often explain the rationale and then we get people to think how does it fit them. In ADepT we're allowing conversation organically to explore areas. When we've switched something on and we've experienced it, we brought it back into mind, then we introduce the formal framework afterwards and that changes it a bit. Just a clinical example about how difficult and challenging that is, we've done a lot of co-design work around ADepT and one of the service users that has helped us do the work is called Katie, she's happy for me to use her name. She talks about at 30 after a reasonably long history of inpatient and outpatient mental health going, she didn't know at 30 who she was as an adult. One example she goes is, am I the kind of girl that wears make-up or not?

 

I said, I don't know, should we try it out? Her therapist, Megan, tried it out with her and it was doing behavioural experiments. Let's put some make-up on, see where that goes with you. What's it like? So you can try this stuff on for size in small steps, not suddenly flooding people to expect to know exactly what floats their boat. You can, almost the end goal of therapy is, I've got them much clearer map after 20 sessions of what's really important to me. So now I know how to live my life.

Rachel: It sounds like a really lovely approach, especially for those people who miss that sort of developmental window where they are culturally supported to try things on for size and see where they fit. Actually, often people with these early traumas or long-term experiences of depression just haven't had that opportunity, have they?

Barney: Yeah, absolutely. But I'm also struck by when you live with depression for the long term, the fear of falling back into the abyss actually paralyses you. So you feel like you're walking through life on a tightrope. And if I take a step the wrong way either side, I'm going to crash down into the ravine and break my legs. And what that does is it makes you see the world as one ginormous series of threats that's going to reactivate my triggers. And in a sense, what we're trying to do is just to get people to rediscover that curiosity and playfulness. We're trying to get them to reframe us. Think of life as walking through a forest. There are loads of paths you can go down. Some of them will be cul-de-sacs or get you somewhere dull or somewhere painful, but lots of them are really interesting and fun. And if you get to one that doesn't work, you can always just turn around and come back. So we're trying to move people from an all or nothing, and unless I get it right, it's going to be awful to I can play with this. I can experiment with it. And that's a big part of the therapist style in ADepT is be open, be curious, be interested, see potential, even amongst the difficult and the dark. Well, I'm sorry to hear you've had a really difficult week, but what can we learn from that about how your depression's tripping you up? How can we give you new skills here?

Rachel: So it sounds like that black and white thinking can be applied to the positive equally as to the negative.

Barney: Yeah, well, and we definitely see that unless it's a perfect 10, it's not worth having. So that means people are constantly monitoring is my half term trip with the kids a perfect 10 or is it like most half term trips with the kids where it rains a bit and they're sometimes a bit bratty, but we still have some genuinely fun moments. If your depressed mind says, well, there were those difficult moments, so it's all useless, that snuffs the candle out instantly.

Rachel: So that's really helpful in understanding that values piece is a process of discovery and creativity. You talked about the mapping tool at your next stage. I'm thinking about bridges for people who are working in other ways. It sounds a bit like behavioural activation, work in standard ways of treatment, thinking about traps and tracks. Is there a similarity? Is there a parallel there?

 

Barney: There's definitely some traps and tracks, but it's actually closest to Chris Padesky's Strength Based CBT, one of my favourite papers in CBT. So read how she talks about, you can use a hot cross bun to formulate challenges and difficulties and what trips people up, or you can use it to lean into what allows them to run with good stuff. And you can do that both around the good and the bad. So you can formulate this really difficult thing coming up. Maybe it was, I had a really difficult encounter with my boss at work. I could formulate all the ways my depression tripped me up, or I could formulate all the ways I was able to be resilient, so I still managed to get through that meeting and achieve my objectives. So you're putting, you're using your simple CBT, hot cross bun, to formulate in a strength-based solution-focused way, what can I do here to get closest to what's important to me.

Rachel: Then you move on to the systematic techniques to kind of build on that, enhance that, it into day-to-day life towards wellbeing. These sound like techniques that we could all benefit from using, is that right?

Barney: Yeah, mean, absolutely. So when we're training therapists to do ADepT first, it's really natural as a therapist to have a whole set of reservations about doing this positive stuff. My clients are going to find it so invalidating, it's going to be a bit yucky, they're going to throw up all over my shoes and it's going to be awful. I couldn't do that. My job is to talk about the difficult. So how we get therapists to learn ADepT is try this stuff on for size with yourself and see how it lands and try it on even at times you're struggling a bit or there's a bit of darkness. And a lot of my therapy team would say a lot of us are now thinking about what's important to us in life and how are our patterns of mind tripping us up and how can we go in an opposite direction. For me, it's an interesting empirical question of if you're starting to move towards wanting to build wellbeing and a values consistent life and acting opposite to mechanisms of mind that do it, have we really invented a depression treatment or have we invented a fairly trans diagnostic life coaching approach? That it doesn't matter if you're depressed or anxious or you've got an eating disorder or whatever, we've all got patterns of mind that trip us up. We all could benefit from moving towards stuff that's more important and values consistent for us.

Rachel: and drinking a coffee mindfully.

Barney: Well, so that is another interesting aside. So the classic rationale for mindfulness-based cognitive therapy. So I've ended up running a mindfulness service despite my kids accurately describing me as the world's least mindful man. What I was struck by in the rationale for mindfulness is it's all about when negative reactivity gets switched on, how can you cultivate a non-judgmental, non-reactive observing mode of mind to stop you going back down the negative rabbit hole. But I was struck by the bits of mindfulness that engaged with me more, is it became a tool to let in a bit of light. So rather than just drinking the coffee without thinking about it, realising there's quite a lot of sensory experience in this. How does it smell? How does it taste? How does it touch? And so on. And realising that slightly enriched the experience. And also realising that capacity to observe my patterns of mind. Oh, there's me judging this isn't the perfect 10. This isn't as good as the flat white as I had last week. So therefore it's useless. Oh, there's that old familiar thought. I can just step away from that and come back into the sensory moment. So I'm increasingly interested in maybe one of the active ingredients of mindfulness is how do we build the positive? indeed we've started to show that that is important for mindfulness- based cognitive therapy, having relapse prevention effects. The extent to which you switch back on that capacity to experience the positive stops you getting depressed again in the future.

Rachel: I was reminded as you were talking there about clients throwing up on therapist shoes, all this kind of positive wall of positivity hits them and they're kind of engaging in this different style of therapy where there's therapist cognitions that people have. It reminds me of a myth that certainly used to come up a lot talking to people about CBT, maybe therapists transitioning from other approaches and modalities. You know, they would think, isn't it just all about kind of positive thinking and replacing your negative thoughts with nice positive ones and just decide to think that the world is a nicer place. Does that come up when people are learning about this positive affect focus or the idea that you're not really getting to the root of the problem? It's all quite surface oriented, chopping the heads off dandelions or just convincing yourself that they really look rather nice on your lawn.

Barney: Yeah, I mean, it definitely comes up. I'm someone with what I'd call well-managed depression. So I've probably had 15 or 20 episodes in my life. I do very well on a maintenance dose of Citalopram as an antidepressant. And I've thought really hard about lifestyle factors that help me stay well. And I've learned that the things that help me stay well and manage the depression are not feeding the beast, feeding the other side of stuff. So my world is simultaneously nearly always a mixture of the bad, the meh and the good and it's useful for me to have the attentional choice about where I direct my attention. Sometimes I need to attend to them now, like this morning I had to put some washing on, do the washing up and blah-de-blah-de-blah, you need to have that capacity. Sometimes it's really useful to be able to look at stuff that you're stuck with, it's really difficult, isn't going well and that's the evolutionary function of depression, is things aren't going as we wish, retreat to your cave, lick your wounds and change tack. But we also need the capacity to lean into the good and go, there's an opportunity here. Oh, look there's a new field I could forage, there's a new source of food. And what we need is a balance in our minds to at the right time, switch on the right mindset. Depression's trained us to be really good at leaning in to the stuck and the difficult. And we've basically got an impoverished positive muscle to lean into the opportunities. And so it's just getting clients to go, there's a choice here about where you direct your attention and you don't just want to follow a habitual pattern. You want to be able to make a wise choice at that stage. And it's definitely not easy to do that. When you are flooded with a lot of negative affect and all you want to do is retreat to your cave, shut your curtains, stay in bed, ruminate on things, realising actually what I need here is to get out and do something that normally would nourish me. It's really hard. That's not the easy choice, but it is the wise choice. So I'd say it's not just about thinking positively. It's saying you've got a choice with this complex world. It's a mix of the bad, the good, and the meh, where do I need to direct my attention now?

Rachel: And it sounds like your personal experience gives you lot of credibility and authenticity when you're approaching these issues, both as sort of academic problems, but in real life, in real people's lives and experience. And you're not alone, I think. You can't be alone because depression is so prevalent and just human experiences that we always have ups and downs in life, whether we kind of experienced depression recurrently or not. On the face of it, focusing on positive affect might seem like a preferable approach for therapists managing their own stress and life challenges and ups and downs and maybe depression. How does this work apply to therapists themselves and how might they be challenged? And is there a risk they become avoidant of their own negative affect or are there assumptions they need to challenge? How do people look after themselves?

Barney: Well, before I answer that, I'm going to say that the pitfall with ADepT is people think it's just about pivoting to only talking about the positive. If you just do that and you neglect the negative, it is going to be invalidating. You need that equal focus. So let's for example, hypothetically example, could be a client that's come in, she's self-harmed four times this week because of ongoing conflict with her boyfriend, but she did manage to get the dog out for a walk on the beach. If I just say, hey, I don't want to hear about the self-harm, I don't want to hear about the argument, I just want to tell me about that walk with the dog on the beach. What's the point there? You need to honour and validate the difficult enough to go, so what I'm struck by is it would have been so easy to carry on with that cycle, but somehow you've exited that cycle of self-harm and arguing to be able to do something different. So could we think from that really difficult, challenging moment. What did you do there that stopped the descent or allowed you to turn the corner? So it's not that we're not talking about the difficult, we're talking about the difficult in a different way, which is what were the strengths and resilience you brought to it that stopped that getting stuck in that? And then despite all of that difficulty, you've still managed to do some good stuff. And what was the strength and resilience you brought that allowed you to engage with that positive thing, to show that real grit and resilience that allowed you to get back into life. And if you talk about it in those ways, then when you turn to look at the good stuff, you're not giving clients the message, hey, life's all great, you just need to smell the roses. You're going, you can find good stuff, but sometimes it's really hard work and well done you for managing to lean into and engage it. And was it nevertheless worth having? I guess I'll go back to the example of my dad dying of cancer. Am I glad we hooved around in the garden, driving the mower and ruining the plants? Yeah, was one of my favourite ever memories of my dad. In amongst a lot of difficulty, I'm glad we created that opportunity. And that's the kind of language we're using with depressed clients as well.

So what's it like as a therapist to learn ADepT? Superficially it feels like, that'll be really easy to learn. I can do that already. And therapists are then really surprised at how well trained they've been to attend to the negative and how all of their automatic behaviours are. Great, I caught that negative automatic thought that switched on negative affect. So learning to pivot away from that is surprisingly challenging. It's a bit anxiety provoking, like trying on a new behaviour in public and worrying you're going to be judged negatively, learning not to do that. There's also a sense of people realise it's really hard work to validate the difficult and keep pivoting towards the light anyway. It's hard work for the client, it's hard work for you and it's tiring. So those are the challenges of working this way. But the opportunities are, therapists starts saying, do you know what, to be really honest, I'm not sure I've looked forward to my depressed clients coming to see me each week for the last 10 years, but I'm starting to a little bit because I know as well as working in that really difficult stuff, they're going to tell me about, I've got back to tango or I managed to go on a date night with my husband or whatever. So it brings a different feel into the room that the therapist enjoys a bit more. And similarly, clients start to say that. I mean, how many clients go, okay, I've got to gird my loins and go into therapy and talk about all the really difficult stuff. It's going to be really painful, but I'm not sure I really like my therapist, or they like me. This is a process we need to go through, like going for a root canal at the dentist. Maybe therapy doesn't need to be like that. Maybe you can also go, yeah, this is fun. I can go in, I can celebrate some of the good bits. I can belly laugh. It's okay to experience the good even amongst the dark. That doesn't mean the dark isn't there. And what we've generally found is quite a lot of therapists start adapting themselves and they use it to, they find it as quite a useful kind of life coaching approach really.

Rachel: In a small way, when I've been doing this or aspects of these techniques with clients, I can really identify with that. Those moments where you're enhancing the positive and seeing that positive affect spread across someone's face and maybe seeing them smile for the first time in therapy. It's, it is incredibly rewarding for as a therapist just to experience that affect in the room, even when it's a core part of our work to sit with the difficult and the negative as well.

So you've talked a little bit about some of the challenges people experience. Where are the places people get stuck with this work? What are your most frequently asked questions in supervision or the trickiest issues that come up for therapists working in this way, do you think?

Barney: So I think one of the things is it's deceptively simple to say just reorient your attention as a therapist to notice the positives and they have all the same mechanisms of mind clients do around that. So their attentional bias is much more towards the negative and the minute the positive starts to switch on, therapists then have a whole set of appraisals like, I shouldn't be talking about this. They're going to find me invalidating and so on. So it's teaching therapists to learn a new habit, which is why we just like in mindfulness would encourage people to learn it from the inside out first. Experience this, learn that it works and it's okay. Usually I say to people, because a lot of people I train are 30 to 50, so they might have kids, I go if you can get this past your teenage kids, you can get it past anyone. Getting them to experiment with these kind of ways of questioning with their teenagers and go, oh my God, even they swallowed it. So maybe I can do it with a client.

Rachel: That's a tough audience.

Barney: Yeah, well, exactly. If you can do it with your average teenager, can do it with anyone. The second thing that people find difficult is this is, to come back to that military metaphor, it's not following a manual. It's like being a sniper in the jungle. So how do I know what technique to pull out at what time? The challenge we're having training therapists to do is to be really good at pattern spotting. What's the psychological mechanism we're working on now? So when its around the difficult, yeah, we call them the three horsemen of depression, usually avoidance, rumination and self-criticism. So when clients are avoiding, what are the two or three evidence-based techniques I can experiment with using with them when they're ruminating? What are the two or three evidence-based techniques I've used with them? Yeah. When they're being self-critical and so on. Then get training clients to have that pattern matching approach where they're going, this is the mechanism at play, so this is the intervention element I need to pull out, is a bit different than saying in session four, bring out a negative automatic thought record.

Rachel: Okay. So Barney, let's talk about effectiveness and efficacy. We started out by saying, you know, we've got good evidence-based treatments for depression, but you know, at best, perhaps they're kind of helping a third of people into recovery in the longer term. Is ADepT effective and is it equally effective for everyone?

Barney: Okay, so I'm going to take a step back. The first evidence people need to know about is anhedonia- clinically important. So when you speak to clients, they say it's more important to their recovery than symptom relief. And when you look at the prognostic importance of anhedonia does it predict outcome? It predicts a whole loads of outcomes. So anhedonic teenagers are more likely to get depressed. Anhedonic depressed clients are less likely to seek help and benefit from help. Clients who are left with residual anhedonia are more likely to relapse or have a chronic partial recovery. So it's definitely prevalent and it's definitely prognostically important. The next bit of the evidence people need to know about is, cause a lot of, you know, very legitimate critique is Barney maybe you're just not very good at CBT or BA, when I do CBT and BA I get positive affect back up to better. We don't need to reinvent the wheel here; you just need to be better at CBT. So the way we looked at that is we've gone back to some of the best trials in the depression field, so led out of the Beck Institute and others, and we've looked at how well they normalise negative affect versus positive affect. And the story goes something like this; people are further away from general population averages around the positive and the negative, therapy and drugs repair positive less than negative. So at the end of otherwise successful therapies where negative affects go back to general population typical levels, positive affect is still robustly well below general population averages. And that is the same in CBT.

The next critique I've tended to get is, well, but BA, it's a reward focused treatment. Surely BA is better than that, than CBT. And so we did a secondary analysis of a very big trial called COBRA, which was a head-to-head of BA and CBT in NHS talking therapy settings. And it's the same story. BA also isn't very good at repairing anhedonia. I think because it behaviourally activates people, but it doesn't teach people how to overcome the psychological mechanisms that get in the way of enjoying that activation. It's like taking the horse to water but not teaching it how to drink.

So the last important piece is if you target the positive affect system, will that genuinely lead to long-term wellness? So we've done a secondary analysis of another big trial called Prevent which is Mindfulness-Based Cognitive Therapy for people with three or more episodes of depression, does it help people stay well? Where they also included a positive affect measure and somewhat surprisingly, what we found was having low levels of positive affect predicted relapse over and above all of the other residual symptoms of depression that people had. So reduced positivity was a stronger predictor than residual symptoms. And the extent to which mindfulness-based cognitive therapy switched back on positive emotion accounted for the clients who stayed well over the longer term. So I'm now really confident in saying there's a very strong evidence base that positive affect is prognostically important. Current treatments don't fix it perfectly. If they could, you would help people stay well for the medium to long term.

Then it becomes a more open empirical question of, so are this new wave of therapies like ADepT any better than CBT and BA at achieving that goal? And let's just be really honest here. This is a really tricky problem. Beck was an absolute genius. No one's been able to do much better since. So just need to come at this problem with humility. Even small gains in this area are probably worth having, but they're not easy to get. And where we've got to with ADepT is the strongest evidence for it so far is we did a pilot trial head to head of high intensity CBT delivered under ideal circumstances to ADepT where we randomized 80 patients with depression with anhedonic features to either of the arms. So it's a pilot trial in that it wasn't powered to definitively test is ADepT better than CBT. To do that, you need a big trial with about 500 people because the gains you're looking for are relatively modest. But from that pilot trial, what we can conclude is we're pretty certain ADepT is no worse than CBT. So it's got less than a 5 % chance of clients doing worse in ADepT relative to CBT. And it's a bit of a 50-50 coin toss of do you do the same with ADepT and CBT or do you do better in ADepT than CBT? So we would say that is promising evidence that it's already a viable therapy. We're pretty sure it's no worse and it has a good chance of being better, but we now need a bigger trial to test that out definitively and that's what we're moving on to next.

The other source of evidence in that trial is also the health economics of it. So if you want to implement something in the real world, you have to be able to show it adds value for an affordable amount of cash. And it looks like ADepT has the potential to what's called health economically dominate CBT. So it costs the same to deliver, but because of this wellbeing focus, returns more quality of life, so you get more bang for your buck.

The other really interesting thing in the trial, and again, we're underpowered to answer it definitively, is what were the long-term outcomes? So I'm just going to give you the numbers and you can say whether they seem convincing or not. In the ADepT arm, we got 80 % of people into diagnostic remission post-treatment. And in the CBT arm, we got about 56 % of people into diagnostic remission. Of those 80 % who hit diagnostic remission after acute treatment, only 25 % of them relapsed over the next year, whereas 50% of the folks in CBT relapsed over the next year. So basically, ADepT s getting more people better and keeping them better for the longer term in this pilot trial, which suggests it might have potential to be a more effective treatment. But now all we need to do is take it into a big trial and critically not just do it in my little ivory tower bubble of the clinical setting I work in, which has got great therapists who are really well trained and supervised to see can we pull this off in the real world. So I'd say it's encouraging, but not yet nailed on. It's not worse, it might be better.

It's also worth thinking or acknowledging that ADepT is only one of a number of emerging positive affect therapies that are coming out. There's excellent work being done from Michelle Craske around positive affect therapy in California. There's excellent work from Charlie Taylor developing a protocol called amplification of positivity for social anxiety clients. There's brilliant work by Nicole Geschwind taking Fredericke Bannink’s positive CBT and evaluating it. So I would say if you put those therapies together, is there now a credible evidence base that they're doing better than classic CBT and BA at repairing positivity? I'd say just about yes. Are we yet at the point of saying any one of those emerging therapies is definitely the one you put your money on and remortgage your house on? I'd say no, it's an open empirical question.

Rachel: Impressive early data, certainly. And I wonder if the numbers are too small, the studies are too small at the moment to say anything about diversity within that. Are there people you think, or even have a hunch that this might be more effective, helpful for than others?

Barney: Well, let's come back to the question of size. If you look at most of the sample sizes in most of the trials of CBT for most disorders that we would say these are really good evidence. They've typically had less than 100 people in and they've usually compared them to a waitlist or treatment as usual condition which is a really easy bar to beat. Doing something is usually better than doing nothing. So we're quite happy to say the evidence base for anxiety disorders or eating disorders or whatever is really robust and strong on trials that size. Depression's kind of a thornier problem because we've got pretty good treatments and you're trying to say, can we do better than them? So to run those trials, you genuinely need about 500 people because if CBT is, 50 % optimized, moving up to 60 % optimized is worth having, but you need a large trial. And there's just not been enough funding around to do large trials of those kinds. So I would say it is early data, but it isn't early data. We're just setting ourselves a more robust evidence-based bar around this depression stuff. But now to actually answer your question, can we say anything yet about who might particularly benefit from ADepT or not. You're right, the numbers are too small to do that in a statistical sense. So these are my clinical hunches around it. It works best for people who've tried quite a few therapies. They feel like I've done the talking about the difficult and the distress to death. I want something different. And so we're increasingly now trying it as a what we call a non-responders approach. I've tried low intensity NHS Talking Therapies, I've tried high intensity Talking Therapies. I'm still not better. What do I do next? I'm looking for something different and I'm ready to move to this position of going, I'm not sure I'm ever going to be able to eliminate my depression, but maybe I can tame the beast a bit and live well alongside it. Those are the folks that anecdotally do better with it.

I'd also say if clients aren't saying experiencing pleasure and joy is a challenge for me and something I want more of, well, why would you give them a therapy like ADepT? If a client is saying what's really bothering me is I've got loads of intrusive negative memories coming in, they're not PTSD but they're making me very depressed, I'd probably think, well, you know maybe EMDR. If a client was saying, I've got loads of negative beliefs about self-world and future, and I really want to bring down my negative affect, I'd say classic CBT. But if a client's really anhedonic and they're saying, this is something I'd really like to work with, and I just never had any traction with it, that's where I'd be thinking, ADepT worth a crack.

Rachel:  So Barney, you've worked with people with anhedonia in the context of depression and other problems for a long time now. And it's always such a privilege, isn't it, to work with the folk we work with. And we often learn more from them than we do or possibly than they do from us. And you've also worked with people at every stage of the development, implementation, testing of your work and thinking about developments in the future. What have you learned from people you've worked with?

Barney: Lots in short. The two service users that have most helped me with the co-design of ADepT are Nigel and Katie. So Nigel helped me in the initial development of ADepT and Katie's helped me with more recent iterations for more complex depression. What Nigel encouraged me to do was to be really bullish about going for well-being and positive affect, not just trying to reduce anhedonia but getting people back to meaning, connection and pleasure and encouraging me to go further about doing it earlier with clients and that they wouldn't find it invalidating, they'd find it helpful. It had come from his own experience of being a participant in an MBCT trial where what really helped him work through his depression was reconnecting to the light. And Nigel also brought a whole range of broader experiences in life. We know wisdom as a professional in another field and lived experience to help us think about how to do the values work and do the coaching piece really well of ADepT. Then Katie basically reached out to me a couple of years later and said, I've heard about this ADepT work. I think you should be doing it with more complex cases because I spent a lot of years going through a lot of treatments that have helped me to some extent managed symptoms, but I'm still left with a sense of I'm not sure who I want to be or what matters to me in life. So she's encouraged us to set up this line of work for what we're calling complex depression. These are folks with a complex early trauma background that's leading to difficulties with regulating emotions and relationships alongside depression and anxiety as adults. You might recognise that as a description of personality difficulties or disorders. We're choosing to call it complex depression because we think that has less problems as a term. So we're just completing a case series with 30 people to see can you do this well-being recovery-oriented way of working with these more complex presentations and the headline is it looks like you can. The changes that Katie encouraged us to bring into that protocol were first of all that the values work is really hard if you've never had a chance to work out who you are and who you want to be because life's been very coloured by mental health from a young age. So go slower and leave more space for exploration around values. Also the need to bring in some additional work on giving people emotional interpersonal regulation skills, which is how we've brought ADepT into adept dialectical behaviour therapy elements in a solution focused fashion. And she was also saying, how can you manage the reality of quite often chronic fluctuating risk with these clients, which might be around suicidal urges or self-harm urges and not to allow the wellbeing and recovery oriented focus of ADepT to be too hijacked by that. Because the way you really keep people safe is you give them a life they want to lead. So even when they have strong urges to want to harm themselves, there's a reason to keep living for. So we've been working quite hard about safety plans in a more solution focused language than classic risk commentary. Katie has also very bravely, she came to us and helped us design the protocol but then she stepped out of being someone with a designer and actually received the therapy from one of our team and that's given her an additional set of insights coming back to support us later.

Both Katie and Nigel also do a lot of co-teaching and co-training with me and it really helps to get rid of the them and us between clients and therapists to be teaching alongside as equals. And I asked them before this interview, what are the things you would want me to say about Adept from what you said? I think the main thing that came out was, it really helps to let go of symptom relief as your primary aim, learning to live well alongside depression and get back to wellbeing is the thing that they found most important on their recovery journeys.

Rachel: Fantastic. We're hearing a bit about where you're moving things forward in terms of these complex presentations and new areas of development. What are the next horizons in this field of anhedonia? What are the next big challenges? What are the problems to solve? The knots to untie.

Barney: Well, alas, it's a slow and steady process. So the next thing we need to do is a really big trial of ADepT compared to CBT to see is it really clinically effective and cost effective when done in real world pragmatic settings. What I've seen a lot of therapy developers do is they rush straight to that big trial after a promising pilot before they've fully ironed out the implementation pipeline. And for me the devil's in the detail and this is where I think David Clark and Anke Ehlers and others have been absolute geniuses in the field. They've really recognised you get you probably get 5 % difference from one protocol to the next, but you probably get 15 % difference of whatever protocol you're doing, training people and supervising people to do it well and creating a system of care in which they can deliver it well. So we've been spending a lot of time learning how to supervise and train folks in ADepT before we do a big trial so that we know it has the best chance of working. But also if we show it works, we'll be convinced it is implementable in an NHS Talking Therapy setting. The other bits of work we've been doing around the edges is in the pilot trial we found there were a few rough edges that we were less sure how to work with, reflecting the heterogeneity of depression. So I've talked about one of those already, folks with more complex trauma backgrounds, what you need to do differently for those. Another group we're interested in is neurodiversity, because generally those folks do less well in classic CBT approaches. So we're doing a case series and have adapted ADepT for folks with neurodiversity so that we can then weave that into the universal protocol about think about this if you're working with someone with ADHD or varying degrees of autism. The other piece that we're doing is trying ADepT for minoritized groups because a very legitimate criticism is of the therapy at the moment is to paraphrase, is it a bit too white Waitrose? And will the same techniques and approaches work with people with significant more kind of life grip in their oyster and or people who've come from different cultural backgrounds? So we're deliberately trying out the protocol with those folks to work out what are the tailoring and adaptations we need to do. We're putting all of that learning into the treatment manual that we're currently writing because we want it to be a book that recognises that working with depression is, it's come back to that military metaphor, it's a bit more like guerrilla warfare, you need a variety of different skills in your armoury to bring out at different times, rather than rushing straight to a big trial, where we don't think we've quite optimised the protocol before it. Because to be blunt, what happens after you've done a big trial is therapy treatments then get locked down. It becomes a bit like a stone tablet brought down from Mount Ararat and it becomes harder to innovate and change. So we want to make sure the protocol has got as far as it can before we invest all of that time and effort and taxpayer money into doing it.

Rachel: So before we have that stone tablet and people have the ultimate authority on how to implement this work, how can they learn more? How can they start to implement this in the therapy? How can they get training?

Barney: Well, there's two ways that these kind of techniques and ideas could be integrated into CBT practice. And the honest answer is I'm open to either of them. You could think of ADepT as a standalone therapy that you wish to be trained in. And we do various one-day workshops and there's lots of papers I can get you to read that we can link to after this podcast. But the other way you can think about it is that many of these ideas can be weaved in in a way that has fidelity to classic Beckian CBT into the work that folks were already doing in their high intensity therapy practice. And I give a lot of workshops saying here are some ADepT informed ideas that you could weave into a standard CBT treatment in a way that's entirely consistent with a Beckian way of working. And that's how I do encourage people to learn more at the procedural level. But what I would say is remember, another one of my heroes is James Bennett- Levy. I love all his work about how to train and get people to do therapy through the declarative procedural reflective model. The best way is try this stuff out on yourself. And it doesn't need to be super formal and perfect. Just play with solution-focused questioning, positive journaling, just see how it goes. See if you can find any benefit in yourself. So you also, if you can get it past your teenage kids, if you can do that, you're ready to explore with it in your own therapy practice.

Rachel: Fantastic. So in CBT, we like to summarize, as you know, and think about what we're taking away from each session. I think it's almost hard to do better than Katie and Nigel's pithy statements about learning to live well with depression and enhancing well-being. But what key message would you like to leave folk with regarding this work with depression and anhedonia?

Barney: For a CBT audience, think about positive affects as though it's an anxiety disorder. People are afraid of feeling positive. So the way that you can help folks work with it is a graded exposure hierarchy back towards what they love and matters to them, encouraging them to let go of safety behaviours as they go and build alternative strategies.

Rachel: Thank you so much Barney for your time and all the wisdom that you shared with us today. Really look forward to seeing you again soon and people will take so much away from this. Thank you so much.

Barney: It's been a privilege. Thanks for having me, Rachel.

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