Patrick Luyten: treatment of mood problems needs to get rid of the old one size fits all

"Perhaps the time is ripe for a radical shift in the treatment of depression in young people." Professor Patrick Luyten seems to have been carefully optimistic when choosing the title for his keynote lecture at the ESCAP 2017 Congress. Luyten, expert in psychoanalytic studies at University College London (UCL) and the University of Leuven (Belgium), pleads for a more person-centred approach of mood problems, a greater focus on developmental factors and underlying vulnerability, and less parent blaming. And, of course: he is a known advocate of mentalization-based treatment.

Prof Patrick Luyten (London, Leuven).Patrick Luyten: "It has been a major achievement of our field in recent years to develop relatively effective treatments for young people. However, at the same time, we are realizing more and more that these disorder-centred approaches have their limitations, in the sense that the label of 'depression' covers a very heterogeneous group of individuals. For some young people in this group, more focused and targeted interventions that specifically address mood problems, are quite effective. Yet, for a large sub-group with the label of mood disorder and depression, these treatments are not so effective. In many cases they actually might appear to be quite ineffective, if not harmful."

– What would be your alternative?
"What we need is a more person-centred perspective where we take into account the developmental history of young people in diagnosis, prevention, and treatment. There is a large population of young people that suffer from 'mood problems and depression' but who also suffer from many other problems. It is often said that the level of comorbidity is high amongst these youngsters, but that is in itself a logical fallacy: we are talking about young people who suffer from complex problems, and they express these problems in various ways."

– It is a spectrum disorder?
"In a sense it is. Recent studies – for example by Avshalom Caspi et al. – suggest that it is, and that there is one general psychopathology factor underlying both internalizing and externalizing disorders. If you are low on this general psychopathology factor, the so-called P factor, then it makes sense to look at isolated disorders – this concerns young people that struggle with developing their autonomy, their identity or relationships. While processing these issues they become slightly depressed or anxious, or they develop an eating disorder... For these young people it makes sense to focus specifically on feelings of depression, anxiety or eating disorder problems. But with the other large category of young people – who score much higher on this P factor – we should not focus the treatment specifically on one disorder. Because that disorder is only part of the spectrum, of a more general problem."

– What should be changed in the clinician's approach?
"I expect there will be at least two shifts in diagnosis and treatment. In the first place: we should take into account the developmental psychopathology perspective – the developmental history of the individual, including its context. Diagnosis and assessment should be clearly geared at identifying the complexity of the underlying vulnerability. It is this complexity that will determine whether we can refer the young person to a very focused and brief treatment, versus having this person undergo a much broader and often longer term treatment."

– Trauma would be an example of this more complex category?
"Yes, trauma would be a good candidate for the complex category. Trauma is a kind of eco-phenotype, it is non-specific, broad vulnerability factor that is implicated in a wide variety of disorders."

Risky environment
Prof Patrick Luyten (Leuven, London).
"But it gets even more complicated. Taking into account the environment in assessment and diagnostics will add to the complex picture. What we see in these youngsters with very high 'comorbidity', is that they are often growing up in a very risky environment. And not unless we also intervene in the environment, and in the capacity of the young person to contribute to change his or her environment, a treatment may be effective."
"The second shift is that we should target the underlying vulnerability. This again has much to do with the person's environment. We cannot simply focus on what is happening inside the head, inside the mind of a patient. The environment contributes not only to the onset of the disorders, but also to the diagnosis of it."
"This would lead to a much more focused way of treatment, instead of the old one size fits all approach."

– You are an advocate of mentalization-based treatment?
"Mentalization-based treatment – MBT –may be a very effective treatment for young people with depression. But let us wait for more evidence first. One of the reasons may be that MBT specifically targets one of the key features of depression. Depression inhibits the young person's capacity to mentalize, to reflect on wat is happening to him or her. Focusing on this capacity may liberate this in-built evolutionary capacity for social learning: to see what is happening to you. You learn from another person who teaches you what could be happening to you. Becoming conscious of your social environment may help you to get out of the vicious cycle, or downward spiral of depressive symptoms and depressive mood. But MBT is only one method to address mood problems in young people."

Becoming more integrative
"We need to know much more about the mechanisms involved in depression in young people, and how we can specifically target them. Mentalizing is one approach, and focuses on social cognition, but the reward system is another very important area, as well as stress and adversity. An approach, geared at targeting key mechanisms allows us to focus. We can address, for example, the individual's coping strategies and interpretation of what happened to him or her. Again, this approach should also help us to intervene in the environment. But keep in mind that there is no MBT brain, no CBT brain or an exclusively biological brain. These are ways for us to approach the individual and his environment, and one of our challenges for the near future is to become more integrative, not only as a science, but also in terms of prevention and intervention. It seems that treatments will be effective, in so far as the individual feels validated and mirrored by that specific treatment approach. The patient needs to recognize that someone genuinely cares for him or her – this recognition might be triggered by many approaches. For example, a purely behavioural approach may mirror problems with inactivity, typical of depression. So, if the behavioural therapist focuses on this inactivity and the importance of becoming active again, the individual might feel recognized by this therapist who seems to understands some of the problems that he is struggling with. By someone who genuinely cares for you. And who has knowledge that appears to be valid. Similarly, a therapist who focuses on the need to be recognized by others, may also trigger the feeling that the therapist really understands what the depressed individual is struggling with. Thus, there may be many routes into depression and its treatment, but the core mechanisms may be the same."
"These considerations have led us to argue that there are three levels of change in any effective treatment of mood problems – and probably in the treatment of any type of psychopathology..."

Epistemic superhighway
"The first level of change tells us whether the individual feels validated and recognized by what the treatment offers. Do I perceive the knowledge that is conveyed to me as valid knowledge? Do I recognize what the therapist is offering as applicable to me? This might be a focus on behavioural activation, on dysfunctional attitudes, on automatic thoughts, on impairments in mentalizing, and so on. In so far as the knowledge that the therapist is felt as applying to the self, this engenders epistemic trust. This is not so much trust about the therapist as a person – but about the therapist as a trustworthy source of knowledge about the world. In effective treatments, the young person feels validated and understood, which will open up a so-called epistemic superhighway. It opens up the young person to start considering different alternatives as to how to look at him or herself, how to look at others, and at oneself in relation to others. So this process opens up an evolutionary in-built capacity to learn from the minds of others."

Training the basic
psychotherapeutic skills
"These views actually emphasize the importance of proper training for psychotherapists. Psychotherapy might be a science, but part of it is also an art. The danger at the moment is that we are training therapists as a kind of virtuoso experts in providing techniques and interventions only. But let us not forget about the basic psychotherapeutic skills, such as the capacity for genuine empathy, for listening, for being able to relate to other people in a kind and genuine way."

– So half of being a good psychotherapist is simply being a nice person?
"There is lots of research evidence that seems to support these assumptions. For instance, if you look at the effect sizes of cognitive behavioural therapy in treatment of adolescent depression, you will see that these are decreasing across time. There are probably various factors explaining this. However, one factor that might have had an important influence on this decrease, may actually be that therapists are beginning to believe that the effective components of this CBT treatment are the techniques only. They start to focus on the specific techniques, sometimes even before they have paid attention to relate to the individual, to build a relationship, a working alliance. Aaron Beck, the founding father of CBT, has always warned for this."

"The second level of change is about mentalizing or, more generally, social cognition. Feeling validated and recognized as an agent, the individual's mind is now opened up to consider new perspectives. On oneself, others, human relationships and on the world. Any good theoretical approach will lead to improvements in mentalizing, which will enable the individual to actually change."

"This leads to the third level of change which involves salutogenesis, or social learning, the capacity to learn and benefit from other minds outside of the therapeutic relationship, in the real world. This ability holds a major implication for treatment, namely that effective treatment should aim at empowerment of the patient so that he or she can continue the process of therapeutic change outside and after the end of treatment."

– You mentioned prevention a few times. How does that have to change to improve?
"Indeed, another field where we could reach a major shift in the future is prevention. Here I see a large role to be played by the government and education in decreasing stigma around mood problems and depression in particular. Governmental policies and school curricula should include a focus on emotions, for relationships, and for mental health issues in general. School-based programmes could be helpful as a next step in targeting at-risk groups, not the entire population."

"In a way, it is quite funny how current education teaches young people everything about the economy, the human body, mathematics, history and science. But the thing that is most important to them, their own mind and relationships, we teach them least about."

Harmful system
Professor Patrick Luyten (Leuven, London).
"The influence of parents on their children's vulnerability for psychopathology is potentially massive. This is not to blame parents, because we know that a lot of the influence that we observe is directly genetic: intergenerational transmission of psychopathology or vulnerability to psychopathology from parents to children. But there is more. We already discussed the so-defined 'risky environment'. If there is one thing that we have come to realize, based on developmental psychopathology studies, it is that children and adolescents, even more so than adults, are part of a system. A family system and a socio-cultural system. So if we want to address mood problems in young people we need to take the family environment into account. For youngsters with a 'pure' depression this might not be a high priority, but for children with complex comorbid problems, we cannot treat them without involving the context. I could do hundreds of brilliant sessions with a depressive adolescent, but if he or she, after the session, returns to a very harmful context, very little is going to change. For the broader environment of the young person – like his peers – salutogenesis plays an important part again: what are the abilities of the young person to benefit from the environment? To foster empowerment includes for example to help the young person to develop this filter to determine what the positive forces are, and which ones are potentially hazardous."

– Some say that the prevalence of depressive adolescents is rising.
"We do not know if depression amongst young people is increasing. We have very few representative studies on the prevalence of depression, especially amongst young people. In the UK and the US we have some, but we have to take into account that the threshold for admitting mental health problems is lowering and there are differences in methodology. So depression in adolescents may be on the rise, but we are just not sure. So I am not convinced that the increase in depression amongst young people is real. Those who do say so, have too little evidence in my opinion, and simply blaming the parents for it seems slightly dangerous to me. That would be too easy, particularly because many of those so-called parent-to-child effects are misinterpreted – in many cases they reflect the opposite process: these could be child-to-parent effects, where the interaction is actually driven by the child, not the parent."

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