Psychotherapy and Applied Psychology

Cognitive-Behavioral Therapy (CBT): A Key Player in the Evolution of Psychotherapy with Dr. David Barlow

• Season 3 • Episode 40

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Dan is joined by Dr. David Barlow, psychologist and Professor Emeritus of Psychology and Psychiatry at Boston University.

Known for his world-renown research in anxiety disorders, Dr. Barlow joins Dan to discuss the evolution of psychological practices, particularly the transition from traditional behavioral therapy to cognitive behavioral therapy (CBT). Dr. Barlow highlights the historical context of therapy practices, the debates surrounding cognitive and behavioral approaches, the misconceptions that persist in the today's field, and the importance of understanding underlying traits like neuroticism.

Special Guest: Dr. David H. Barlow

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders

Neuroticism and Disorders of Emotions

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[Music] It's not hyperbolic to say that today's guest has had more influence on the science and practice of psychotherapy of the last several decades than almost anyone. In our conversation, we have the pleasure of learning about his perspective of the field's development and his role in that development over the past half century. Today, you'll learn from my guest about how behavioral therapy became cognitive behavioral therapy, the controversial role of Aaron Tim Beck, my guest's less than flattering perception of Albert Ellis, is much more generous pushback on the common factors model, and the role of clinical trials in establishing psychotherapy's credibility. But first, if you're new here, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to psychotherapy and applied psychology, where I dive deep with leading researchers to uncover practical insights pull back the curtain, and hopefully have a little bit of fun along the way. If you enjoy the show, do me a huge favor and subscribe on your podcast player, or if you're watching on YouTube, hit the like and subscribe button. It's one of the best ways to help us keep these conversations going. This episode starts with my guest responding to my question, but would let him into studying psychotherapy in the first place. So without further ado, my very special guest, the Dr. David Barlow. It goes back to the 1960s when I was at Notre Dame. But you know, like a lot of kids from major in psychology, as I learned over the years, I think had many of them over the decades. You know, I was one of those kids who my friends were saying to me, boy, you know, some issue would come up that was difficult. They say, boy, you're good listeners. You're easy to talk to. You know, so I get these compliments. And that was really helpful having a conversation with you. That's number one. And number two, I was always, always innocent, you know, as a kid, a young kid. And why people do the things they do, you know, why did you do that instead of this? Why did you take that risk? Maybe, you know, do that risky thing. Well, why did you start dating that girl or boy when you were planning it, but it's always just sort of fascinating by that. I was in college. I used to work in the dining hall. Make some extra cash, you know, to have some spending money. So my job was to check people in. You know, we had a big speaker list. No computers in those days, obviously, just just check people in. Long list of people. So, you know, it was pretty boring. And I got to learn all the numbers. So, you know, so I used to experiment. I put signs up in the front, you know, tonight, only. Then it would be from say, 530 to 7 or something. Say, tonight only, dinner from 530 to 7. I just want to see how they react. And not get all these questions. I guess some strange questions, quizzical looks. Some people would ignore it. Not kind of stuff always fascinating. So I was a big kind of practical joker. But what I was interested in was the different reactions people would have to these contexts and situations. So I had that kind of inherently. And then. When I went to Notre Dame, ironically, they didn't have a psychology major. I didn't know that when I went there or if I did, I didn't pay any attention to it. And it was around freshman year. You know, late in freshman year in college, when I said something came up in psychology. There was discussions. I don't remember what it was. But I said, no, well, that would really be neat to be. I could actually study this stuff, you know, for a living. You know why people do this. Now I discovered they didn't have a psychology major. So. And I didn't want to leave Notre Dame. I love being at Notre Dame. In every other way on my friends were there. And. So they had courses here and there. And I was actually a sociology major. But I took enough. I could scramble taking enough psychology courses, some in education, some in sociology, some. One or two else with night courses. That I could patch together enough. And then one summer I had to. They didn't have experimental psychology needed a lab course to be able to apply to a gradual program in psychology in those days. You probably still do. And so I had to take a intensive summer course in Boston. But one summer I had to not work, but take a summer course. So it's all happened. So in deputy what happened as we were just mentioning. The guy teaching the course. Oh, they had I looked, you know, Boston's plenty of universities and all of you still in Harvard, and talks. And Boston college and be in Boston, university. But many of them had three credit courses. But Boston college BC had an intensive six credits and six weeks. So basically the class met three hours every four days a week. And then the fifth day was lab. Very much all day. So, but the guy teaching it. So that's perfect for what I needed was a guy named Joe Cotella. Now you may not remember or heard that name. He turned out to be one of the founding fathers of behavior therapy. He had himself. Studied with Wulpe back around 1960, 59 or 60 after Wulpe just came to the United States. And was at the University of Virginia. And. And this made a lot of sense to him. And he had in turn had a deep influence on me and arranged for me. So I went. So when it came time to apply for graduate school, he said, why don't you come here? They didn't have a PhD at a master's program. But. You say we could keep working together. And so that was great. My hometown. And plus they had, which was a little bit unusual in those days, they actually had a tuition stipend for me. No, no stipend, no wage wage in a stipend, but tuition remission. They had for me. So. So I ended up going there. And then he introduced me to Joseph Wulpe. This South African psychiatrist. By that time, I'd moved to Philadelphia. And Temple University. And then I got to go and spend the summer working with training with Wulpe. So and by then it was 1965, I think. So it was the. I was sort of in on the cutting edge of things back when things were a little strange and weird. And I said, you're doing what? You know, it's not brainwashing and all that stuff. You know, why would you do that? Because nobody nobody was doing that in those days. So let's a kind of long version of how I get into it. So one of the things. And obviously this is well before my time. But my understanding is you were very much trained in a behavioral tradition. And then at some point. And then the thing gets introduced. Right. That wasn't, you know, now we sort of talk about cognitive behavioral therapy. And we sort of group these things, right? But that it wasn't that way. And so I was kind of curious about your experience of that. And sort of your experience of like, oh, these people talking about these thoughts. And that sort of thing integrating it. What you were seeing around you. What that was like. Oh, it's incredible. I mean, people nowadays wouldn't believe it. And it was a war. You know, in our field. I mean, it was a knock down drag out fight. The likes of which you see today and you know, politics are in some academic areas. And. So when the. Cognitive therapy. And so we were also doing this. Which was really initiated by Tim back. Who went on to do great things, of course. Do you think you know the net. You think him more than Ellis. Yes. Yeah. Yeah. Tim back. Was. In my. I think you can make a very good case. Like, uh, elbow. And elbow Ellis was. Um, you know, a character. I don't know if you ever saw tapes. Yeah, yeah, yeah, yeah. And a. Is rational emotive therapy. You know, was. He would. He was a promoter. You know, this is my opinion now. You know, he was a promoter. He would. He was a. A salesman. And he go around and say, well, rational. Motor therapy is a behavior therapy to a behavior therapy. And he go, rational. Motor therapy is a cognitive therapy to a cognitive. And all rational. Motor therapy is a psychodynamic. You know, he was selling something. And. And he was, you know, a clever clinician. You know, he would interact with patients in ways. Almost nobody else would. So. So. That had some influence, but it was an influence in those days. But Tim Beck really came in with some. You know, this whole notion of. Focusing on attributions and appraisals. And cognitions as the principal mechanism of action. No one had thought of that. No one had believed it. And it was heresy. And. So. When a. ABC. What's. We now know as ABC key. Association for behavioral cognitive therapy. In those days. It was a. A. B. T. As you may know, which was. Association for the advancement of behavior therapy. That was the original title. Stuck on it by. Cerebral. Franks. Hans Heisen. And the British group. Jack Rockman. Who was. You must have known Jack. Hearing his years at. You'd be safe. Yes. Yeah. So. Of course, at that point, he was Ising's fair head boy. Over in London, you know, in the 60s. And he was the. He was the air. And he was the air. And he was the air. And he was the air. And he was the air. Of the. Eisen. Key and kind of. You know, behavioral approach. And it was very much based on. Kind of a classical conditioning notion. Pavlovian. And this came from wallpaper and ising. They're all of a group. And everything was sort of thought of as. You know, classical conditioning. And it was just to briefly bring in the other strand. Of course, the. The Epskinner. And was. Was publishing and writing in Boston. And some of his students were doing some really interesting things with. Some of the most severe. Kind of psychopathology. The real institutionalized psychotic patients. And they were doing. You know, taking their operant. Principles. And applying it to that. And so. The traditional behavior therapy types. I think. Rock. And wall. I thought that was interesting. But probably wasn't widely applicable. You know, to. Say the. Population of what was then called neurotics. And so. The traditional behavior therapy types. called neuronics. It was more perhaps applicable to these non-burble populations where you didn't have the option to talk to people for the most part in a rational way at least. So that wasn't really, let's say, a threat that was saying, "Oh, well, that's interesting for those populations." Yep. Let's include that in AABT, that sort of thing. But then Tim comes along with cognitive therapy, and he had been working in his own ideas for maybe 10 years in the 60s. So the early 70s, when people really began to be aware of what he was doing, and he had developed some adherents. He was also very charismatic. Tim was a very pleasant guy and fun to be with. But anyway, he also was, an excellent therapist. He thought deeply about things, and he did some research. And changing cognitions, he found to be, and appradiations seem to be kind of central. He developed it out of his clinical work, but he began doing collecting some data, doing some research. But we went to introduce that to AABT in the early 70s, all hellbruckers. I mean, it was a heresy, and people were saying, "We can't have that stuff." It was like today, you know, where everyone's canceling everybody else. So we can't have that stuff in our association, that's not behavior therapy. You know, that's something else. I know what the hell it is. It's not behavior therapy. So I was actually, it was interesting. Back in the, so more anecdotes, my students would kid me about all the anecdotes I give. So cut me off if I straying too far. Ah, I love it. It's great. But back in the early 70s, I think it was 73. I was a young guy, you know, just early on in faculty and Kautella, come back to Kautella again, is one of the early presidents of AABT. So he makes me program chair of the convention. So I'm organizing the program, such as it was. Now, AABT started out as just one day of paper reading sessions at APA back in 67. So that was the first time we all met together. And I actually gave a paper. So I read a paper. That there were no posters that, you know, there wasn't much else. You just get up and read a paper. And people asked you questions. That was it. So, um, but by the early 70s, I think at 1969, we was the first time we had our own location, our own venue, you know, where we had a meeting separate from APA. And by the early 70s, you know, that was established. And so I invited much to the annoyance of some of my colleagues, Tim back to come and give a little workshop on what he was doing. And Tim was delighted, sure, I'd be happy to come. I'll bring some handouts, you know. And he brought like 25 handouts. He used to tell this story in later years. He brought like 25 handouts of some other, some of the principles, as he saw them at the time, of how we did cognitive therapy. Well, 200 people tried to crowd into this little room with that, maybe 50 or 60, you know, at most. They were pouring, they're out the doors, trying to, you know, and we were all shocked. I was shocked that of the interest that the way he had peaked the interest of a lot of these early behavioral therapists, you know, early people who were looking for an alternative to psychoanalysis still, you know, which was by far the prominent approach in those days. Psychodynamic and psychoanalysis. And, you know, he was blown away by it. But what it did was it sort of convinced my colleagues at that time that this was not, you know, this was something that was and he was very reasonable, you know, when people liked him, they decided that this is something reasonable. This is something we need to listen to. We're supposed to be scientists. They have to be reminded of that even in those days, you know, that you're supposed to be scientists. That means we listen rationally to ideas. We decide how to evaluate them and test them, you know, and we should be relying on the data, not our, not our, you know, personal beliefs. This is what makes us different from the prevailing, you know, schools of psychotherapy. So obviously it, it, it, ought on solely still a lot of debate and hot debates, but by the 80s, by 1980s, the well established and people were saying CBT by around then, although the association didn't change its name until I was in 90s before they officially put cognitive in the title of the association. I didn't even know a little bit later. Yeah, I feel like it was because I was aware of it. And yeah, so I think it might have been. So what was, what was your experience of it in that you're trained in this very behavioral tradition, which has very specific parameters and sort of what's considered and what's not considered. And then all of a sudden you're hearing people talking about changing, talking about cognitions and attributions and these sorts of things. What was your sort of initial reaction to it and then sort of development into, oh yeah, okay, this makes sense. Yeah, well, I never had the kind of hot opposition to it. You know, I was Joe Catella, who was one of my mentors. Had this, this, this procedure is called covert sensitization covert reinforcement. And what that simply meant was that these things were done sort of in imagery. So for covert reinforcement, you'd have them imagine in the context where there was an appropriate behavior and inappropriate behavior. And they engage in the appropriate behavior. This is all again, sort of roleplaying it, you know, in their heads. And all of the, they get contacted by a substantial reinforcement social or otherwise. So, but it was all covert. But covert sensitization, the notion was if there's a pleasurable but unwanted behavior, like drug drug or alcohol addiction, money addictions, or something akin to that. You know, you imagine, let's say there's a drink right in the your hand, you can smell it, you can do it. And then you get suddenly you notice a wave of nausea beginning. And you know, someone's like hypnosis where you build on that and you can feel that nausea, feel the bile and your throat. The stuff smells awful, you know, and you try to build up a straight classical condition, try to build up a negative association to the substance. But it was all in your head. So then I was very familiar with that. I actually caught a wolf, a some of these procedures because I'd learned them from my mental. And so to me, the thought that they were cognitive processes that were, uh, and strictly interrelated with behavioral, you know, with, with overt behavioral was not a foreign concept. And it seemed to me this was sort of a logical way to go. So I experienced it in a very, very positive way. And I would remind my colleagues in those days, people like Terry Wilson, Alan Cazden, my contemporaries, back then in an early, other early presidents of the ABC, I would remind them, you know, what makes us distinct is not basically our philosophy of change or our, you know, belief about what the important gradients are. It's actually what makes us distinct is the fact that we are willing to collect data and empirically demonstrate that what we do is in fact has this effect for that effect, whatever the hypothesis was. And then in some cases, it may not have that effect. The data might show us something differently in which case we have to sit back and re-value it. So, you know, the notion of operationalizing the intervention components of collecting data on perhaps hypothesized mechanisms of action would be they cognitive or behavioral collecting data in an ongoing sense, not just pre-post. We could actually look at the change process. That was another innovation that really came from the operant group. You know, in those days, there was very little science going on to speak of, but what science there was had pre-post measurements. You know, I said, you get the baseline, and all of a sudden, well, we say, "Lady, look at this." Oh, they're a little bit better. So, but, you know, the the operant people said, "No, we should be measuring focusing on individuals and measuring change right away along in looking to see what's going on, you know, what are the, what was the local context of the change?" So, I would argue that that's what made us distinct as CBT, practitioner, if they're reliance on science, they're reliance on empirical approach. The willingness to be open about the mechanisms of change wherever the data took us. And, and, you know, most of them agreed. I mean, it wasn't like I invented that concept as sort of basic science. And so, there are other people who said, "Yep, that's absolutely right." And as we discussed it, we came to agree. And so, I would notice that people who were by 1970s, 1980s, I noticed that people who were militantly behavioral and militantly cognitive. Like David Clark, he was militantly cognitive in those days. Still, he was in some ways. David Clark in boxing. But we'd have these discussions. And he came along in the early 80s, he's a little bit younger than I am. We'd have these discussions. And, you know, gradually, I think everyone got to be on the same page that collecting the data, looking at the change processes, being rigorous in your evaluation of these, was really our distinctive contribution to interventions. Well, that seems to be in some ways a theme throughout your career, where at first we're talking about sort of changing the, you know, from radical or sort of very much behavioral to sort of integrating and transitioning into a more cognitive behavioral based on the data. You did sort of a simpler thing in terms of how really conceptualizing psychopathology, moving from sort of this categorical or diagnosis specific and sort of focusing more on that in terms of treatment into a more dimensional model, in particular, focusing on the underlying construct of neuroticism or trait neuroticism. So I wonder if you could talk a little bit about your experience sort of that transition or what that was like. Yeah, yeah, that's a very interesting story. Focus of my, let me say one more thing though about the kind of what we switch over to the classification issues. So, you know, by, by the, by 1980 or so, as people again integrate cognitive and behavioral, people begin to say, well, you know, maybe, maybe what we're doing doesn't stop there. Maybe we should consider affect and maybe that's like a third leg, you know, on the stool. And maybe there are other legs. We should consider turned out to be there where, you know, of course. But I'll say this because I just came across, I was perusing the journals yesterday, which I still do to see what people are doing. And someone said, we need a new society focused on effective change. And there was emotional or affect changing, affect. And this would be a real contribution, something. Well, in 1980, because these people writing today would know this. But in 1981, the title of Terry Wilson's president to AABT was, if we're now focusing on cognitive cognition and behavior, can affect be far behind. It was right, except it took several decades for affect, to sort of catch up, you know, the focus on affect. Other people were working on emotional, the emotion theorist were focusing on that. They were sort of locked by themselves. And so, again, and then of course, we began looking at context, cultural context, and they were, you know, all of these things sort of, but turning to, oh, can I ask you a follow-up question? Just based on what you're just saying. What do you think are the major misunderstandings or misperceptions that people have of cognitive behavioral therapy at large? I feel like you were sort of hitting on that. Yeah, well, I think it changed over the years. In the 70s, we were, aquatic, choozo or a derogatory name. We were the devil incarnate in the larger field of cycle therapy. Interventions. We were depersonalizing the individual. We were really engaging in brainwashing. If we incorporated any operant procedures, we were bribing people. And what we were doing there were there actually proposals put forth in various organizations, state and other professional organizations to brand what we were doing as unethical. No, of course those were the clockwork, arboring stays. I don't know if you ever saw that movie. Yep, yep. That was a hit movie back in the early 70s, I think. So that's how we were categorized. People say that's silly. I mean, it's not just silly. It's harmful. How could you want to do that? You know, potentially be nice to it. And particularly, people using the versus procedures back then, that was part of, I came right out of the amelette, the versus procedures. Things you didn't do now, but in those days it was kind of a natural extension for some of the addicted behaviors, some of the other behaviors for the really disabled, you know, developmentally disabled kids, you do some brief punishments, even brief shocks and stuff like that. Well, of course that fed right into these conceptions of being, you know, just the brainwashes. Nowadays, all that, and then all that changed, not the diverse stuff. We gradually, from the scientific point of view, moved away from that and discovered, like, a dealing with the autistic kid, autistic cases of all ages, very, very severe, self-injurious, you know, poking your eyes out. So, you know, the most severe that kids don't respond to much. That still, increasing communication, increasing communication skills, where as effective or more effective than a versus procedures for almost all, all are still still some controversy about all this, but for almost all the kids, except the absolutely most severe. So, anyway, those things have changed. In terms of misconceptions, you know, in my view, and this would be a hot topic too, but in my view, we keep slipping. I see the field trying to slip back into this. How would you describe it? Not really. It's not good. I'm not sure. But this, this non-imperial sort of feel-good relationship, you know, type of approach to psychotherapy. So, you still see a lot of people saying, you know, it's all in the therapeutic relationship. We'll still see that. Some people produce data to that effect. Usually it's, you know, cumular data subjected to mega meta-analyses and things like that. So, it's a therapeutic relationship. And the notion among, and for some of them, some of my good friends, sort of, you know, edge into this, but the notion is that, well, what's important, you know, is to form a good relationship with your patient, nothing else matter, nothing else is more important. And then see where it goes. Well, to me, and they say that all of CBT is really based on that. You know, some of these people are great clinicians. And to me, you know, it might be like two things to say about that. First of all, like a lot of things you'll hear me say, it's sort of reinventing the wheel, you know, it's a precurring theme. So, when I was training with Wolpe, so now I go back to the 60s, right? I'm training with Wolpe. What Wolpe used to do? This was unheard of in those days. But he would go over to the psychiatry department at Temple. And they had a weekly rounds, they would call it. And he offered to treat a patient right and find them all. You know, and, you know, there were no one-way mirrors, there was no fancy tech stuff in those days. He was sitting in the middle with a patient. And the residents would all sit around and the psychiatry presence. And the staff on the outside. So I got to go and attend to that. And he would do some failures. What we were considering now is straightforward things like do some desensitization of a phobic, right? And you would do some of it in imagination. I don't know if you would remember because early techniques, it's called systematic desensitization. It was done mostly in imagination, but there would be some, there would be some, some in-lea-well exposure to go along with it if it was convenient. Well, in those days, people thought, you know, again, this is going to, this is going to give the patient a psychotic break. What you're doing is making the manches. You're actually bringing on anxiety. My God, what if the defense mechanisms don't kick in? You know, what if it has a paradoxical reaction? What if there's a reactive inhibition, a shutdown, that you could shut them down, and you can drive them into a psychotic state by making them feel really anxious. Yeah, there was that kind of notion. So, but of course, inevitably, he would treat these patients for maybe 10 or 12 weeks, you know, one hour a week. And every of these patients would get better right in front of their eyes. And they used to pull me aside because they knew I was, you know, at that time, working closely with Wal-Pay, seeing patients every day and observing him and he would supervise me and seeing patients using these new behavioral procedures. And they would say, look, you know, isn't it, isn't it just the fact that he has formed a real strong transference with these patients? And that he's using these transfereds in the way we can't quite figure out yet, but, you know, that's really working to make these patients better. So, being a true believer in these days, and I told Wal-Pay this story later, and a total convert already. So, I would turn to them and say, no, no, it's not his clinical skills. No, in fact, we interchange patients right along, right along the way, you know, going through the desensitization. It's the techniques that work. It's the techniques that are working. So, I had, and later years I felt like Judas added Denai that he was a good clinician. But in fact, he was an excellent clinician. And, you know, I told, I used to tell that story in front of the body, it's when he was alive sometimes he'd be in the audience. So, everybody got a big kick out of that. He was an excellent clinician. But nevertheless, that, I think that is, I think, a misconception holds forth to this day. That no, it's all, this technique really, doesn't matter, it doesn't matter what technique. Bruce Wampold, my good colleague Bruce Wampold, we've had debates many times about this over the years. And, you know, he has this notion. It's all the relationship. It doesn't matter what you do. As long as it's credible, you would say, you know, it's got to be something that's credible to the, to the patient. A credible set of proceedings, whatever it is. But beyond that, it doesn't make any difference. And, you know, he does all this, I mean, to his credit, you know, he produced some data supporting his point of view. And many people, many people would follow on with that idea. And, you know, in my position was always, yes, obviously that's an issue. But what is it about the relationship? Why don't you rather than just saying, well, form a relationship and go forward with it, what specific components are contributing to it? And furthermore, to my mind, the data clearly show that these specific procedures that are targeted for certain types of psychopathology, let's say a specific folder or one hand and bipolar disorder on the other, you know, OCD on the third hand. The specific procedures clearly contribute over and above the, you know, relationship because if you just have the relationship and you have some relatively inoperative psychological procedures or techniques paired with that relationship. Clinical trial, the clinical trial, the clinical trial shows that the procedures, the welcome scene procedures clearly contribute substantial variants, you know, to the outcome, bearing a lot depending on the type of psychopathology you're dealing with. And, you know, every meta analysis, every clinical practice guideline, you know, generated by every professional society, by the National Health Service in London, in the UK, you know, the nice guidelines, national and clinical excellence guidelines in Arkansas, you have to associate some Arkansas law, every clinical guideline to VA that has rigorously examined these things makes that and finding that yes, the procedures usually cognitive behavioral procedures, some others to interpersonal procedures, usually, you know, our first line or second line treatments, depending often the competitive drugs, but usually end up being first line treatments because of the downside of the drug approach and that's over and above the guideline and yet still people will say no, it's really the relationship that carries a day. In my view, so that's, I think one of the major misconceptions. In my view, I was always interested, I was always bearing the same scientific point you were an analytic point of view of the placebo effect and we've actually done a fair amount of work with the placebo effect both drug and psychological. What is it, you know, about that? And it seems to me based on some of our research, but mostly other types of research that there are some very specific aspects of that and the major one might be the expectancies that the patient would have the ability to instill in patients a positive expectancy of change and the other virtue that I think comes across and back came to the same conclusion in his later years. The other virtue that comes across as a very strong contributor is hope and notion of, you know, instilling some hope in these patients. So that I think that in my view, the combination of a positive expectancy, you know, there's all these expectancy scales, you can measure that, you can operationalize that and hope and hope scales, you know, when you get those together, that's what it is about the relationship. It's not just that, you know, well, you're like the guy who at the moment, the person, oh boy, talk about baseball or, you know, events of the week, you know, it's, I think, some very specific things and the argument I always had with my good colleagues who take that approach is why don't you break it down? Why aren't you breaking it down further? Why aren't you looking at what is it about a good positive relationship beyond transference? It was very few people, I think, are into much these days, some of some still are, but you know, what, why don't we do more research really operationalizing some of the, what's going on in a good therapeutic relationship? Other than the fact that it's good and yep, it's good from the therapist point of view, yep, it's good from the patient point of view, yeah, that makes a difference. Mostly, mostly it has to be good from the patient point of view, you know, usually it doesn't make, and our research doesn't make any difference with the therapist, I'm a very little difference with the therapist and the patient, they change their behavior a little bit, but an argument is important that the patient buy in two things, but that's just the beginning, you know, so that's then you have had the procedures. So this is that, I think, that's probably the major misconception. There's a lot of misconceptions, and I won't go on for over here, stop me again any time, but there's a lot of misconceptions that have been along the way about the nature of our research methods. So, particularly back in the 90s, we know the Holy War about clinical trial methodology, and how, how, how, inappropriate that was, but demonstrating the worth of psychotherapy. And we should be doing much more qualitative studies, and, and, you know, something, things that are a lot softer, and things that aren't so rigid. In terms of the protocols that you would do, because that's not what psychotherapy does, you know, you sort of form this relationship, and you see where it goes, and it may change week to week, because, you know, it's different for, so they said, "He's clinical trials, don't come close to approximating what we do, but what I do in psychotherapy." You know, in our response, we'll be, well, maybe that's a good thing. You know, maybe there's too much, say, non-specificity in psychotherapy. Maybe there's not enough attention to the psych mythology in front of you to go to our next topic, and how you categorize it and how you classify it, and what the mechanisms of action might be dealing with, let's say, OCD versus depression versus, so, you know, maybe it's good to get away from this sort of, let's just see where this relationship goes, kind of, approach. But anyway, holy war about your methodologies, but shouldn't use clinical trial, methodology. Now, I will back up, and I'll just say one more thing about this for now, and that is, there's a kernel truth in that, of course. You know, coming at it from as early as the '60s, with something of the people who would consider me more of an operative conditioning type, with my predilection for the whole notion that repeated measures of focus on the individual. We wrote a book in the '70s called "Single Case Experiment of Designs," which was the first kind of concerted efforts, pretty sure, to apply some of the operative methodologies that we use with animals to human cycle pathology, and make it contributory. So, I've always thought that a focus on the individual, using single case methodology, and trying to isolate independent variables and mechanisms of action, in that way, was at least as good as clinical trials, which do have those big, no-morphetic kinds of notions, really dealing with the average patient. And that change you get doesn't reflect any one of these individuals. So, I'm sympathetic to that kind of approach, but anyway, that was another, but nevertheless, clinical trials clearly have their place, and they are the coin of the realm, they're the gold standard, throughout medicine, not just behavioral health, and so therefore, they played a very important role for us as psychologists, you know, behavioral health providers in demonstrating the worth of our procedures and therefore our value in participating in the health care and the system, I think. So, what would it make sense now to talk about your transition from more the sort of traditional DSM categorical diagnoses to this more, the sort of the eroticism focus? That's a wrap on the first part of our conversation. As noted at the top of the show, we much appreciated if you spread the word to anyone else who you think might enjoy it. Until next time.[Music]

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Dr. Dan Cox

Host
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Dr. David H Barlow

Guest