The Evolution of Psychotherapy: From the DSM to the Unified Protocol with Dr. David Barlow

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

Dr. Barlow is back! Dan and Dr. Barlow pick right up to explore the evolution of psychopathology classification, the advancements in treatment protocols, and the development of transdiagnostic approaches in psychotherapy. Dr. Barlow discusses the historical context of psychiatric classification, the impact of DSM-III, the shift towards empirically derived systems, and the need for clinicians to adapt protocols to individual patients.

Special Guest: Dr. David H. Barlow

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders

Neuroticism and Disorders of Emotions

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Chapters

• 0:00 Intro and Overview of the Episode
• 1:30 The Shift to DSM-III and Empirical Classification
• 6:15 Breaking from Psychoanalysis and the Rise of Structured Protocols
• 10:50 Thin Slices of Psychopathology and the CBT Revolution
• 15:40 Shared Components Across Emotional Disorders
• 19:35 The Birth of the Unified Protocol
• 24:20 Neuroticism as the Core Underlying Trait
• 29:00 Personalization and Flexibility in Treatment
• 34:00 Challenges with Treatment-Resistant Patients
• 42:00 Final Reflections and Suggested Readings

Transcript

0:00

[Music] In the first part of this conversation, we explored how modern-day psychotherapy took shape. Its key figures, its controversies, and the science that grounded it. In the second part, we move from the field's history to its ongoing evolution. My guest explains how psychotherapy advanced from broad theoretical models to structured treatment protocols, why personalizing those protocols to the individual patient matters, and how we came to understand neuroticism as the thread running through the emotional disorders. We also discussed the development of the unified protocol, which is a treatment that was developed to be applied across the emotional disorders. 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 buttons. It's one of the best ways to help us keep these conversations going. This episode begins with my guest talking about the good and the bad of how modern-day DSM impacted psychotherapy. So without further ado, here's my conversation with Dr. David Parlo.[Music] Prior to 1980, as you've learned, you weren't around there, but as you've learned. There was no reasonable system of classifying psych mythology. There was DSM-2, there was the early versions of ICD, but they were really just off the top of a committee's head of what seemed to be right, you know, clinically. And of course, the holy grail of classification in those days and continuing to this day was the line between psychotic and non-psychotic. So that was, you know, a crucial lie. Beyond that, things were pretty amorphous. The non-psychotic, among the non-psychotic disorders, the prevailing concepts were a course that go in the litig, and one of the most prominent concepts was neurosis. And as I have written the book in other places, it's really as the 40s. People like Isaac. Well, Isaac in particular, Hans Isaac. Recognized that, you know, this neurosis is such an amorphous, etiologically-based, you know, construct that it's, you know, sort of created, not exactly thin air, but just really someone's, it's a theoretical conception of psychopathology rather than any kind of empirical derivation. But nevertheless, that was the principal way of classifying people. Then as you have learned in 1980 in psychiatry that was all thrown on its head when DSM-3 came out and Bob's Robert Spitzer, Bob, we call him, who was like every psychiatrist in those days trained cycling, literally, nevertheless came to believe, and he was a very persuasive guy, that we really needed an a-theoretical empirically derived system of classification, that to the greatest extent possible would be supported by data. And out of that came DSM-3. Well, you know, that was the biggest holy war of all. It caused just the incredible split in the field of psychiatry. You know, all these people have been trained in psychoanalypt treatment of neuroses. I mean, that was 80% of what psychiatry was. You know, the other 20% was the more organic treatments and maybe in hospital, institutional kinds of approaches to psychotic patients. But most of it was, you know, the one, the psychoanalypt treatment of neuroses. So that was, was interesting to see that, unfold, but he stood his ground and he, he was a free speech guy, you know, he would appear in front of any forum and he would debate anybody and make, and he was very persuasive. So anyway, he got that through. And then, and early on in the early 80s he invited me to join, not to write DSM-3, which I come up 1980, but to revise DSM-3. And the first revision was DSM-3R, that came out in '87. So we continued to that quite a bit, particularly for the anxiety of the sores. And then for DSM-4, where, again, this is a very political thing in the American Psychiatric Association. So it comes down to DSM-4, at least what some people thought it was time to do it. Other people said, "No, that's much too quick." He got booted out. You know, he got the, the hierarchy in APA, the little APA was, the American Psychiatric. He said, "He's got too much power here. He's too much influence." You know, and this was kind of a backlash to his dropping the term the roses, say, "We need to get some fresh blood in here." So they brought in Alan Francis, who was one of his, actually one of his protégés. But Alan was a very precarious and popular guy, and based in New York also, in the same department, you know, Columbia. Psychiatric Institute. And so when I had gotten to know Alan pretty well in the DSM-3R process, so I joined the Task Force to be a simple example. So I was running the Task Force. We made every decision. You know, came through us for any disorder. So that was an interesting experience. This was before the days of, you know, computers and email. Everything was, you know, every two days, I'd get this mailing like this, this thick, you know, that would say. Read these top 15 articles. Very important. You read them before we read again in two days. It was something, you know, I mean, it was just incredible amount of work. People writing review papers and pulling stuff together and topical reviews and data based, you know. So anyway, that was all sort of the process. But what he did, of course, was introduce an Atheorebical categorical approach. Now, as I said many times, this was an incredible advance for psychology. And for, at the time, to go to be, you know, really inappropriate because of the riveting of it. But at the time, it did wonders for those of us who were in the more empirical database approach to psychology because it operationalized the psychology itself for better or worse. Now, these were very thin slices of psychology. But it operationalized panic disorder. You know, that had never happened. GAD, how did it differ like disorder? You know, what was unique about it? And we contributed a lot to that in the mid 80s. Depression, out of that social anxiety. You know, so instead of neurosis, we have 30 or 40 thin slices of what was called neurosis. You know, through the somatic symptom disorders, not alcohol, something else, somatic disorders, and the so-called disorders, and you know, all these neurologists and neurosis. And it was, you know, due to internal conflicts and etc. So now, of sudden, we have these theoretically neutral, empirically derived slices of psychopathology. It turned out to be much too thin, but nevertheless, there they were. And we could develop protocols that actually evaluated, you know, treatments for these. And it wasn't just drug treatments. They'd found a love this development because, you know, they could do the clinical trials on each of these, you know, individuals, all the so-called, and come up with a new indication that would they could get by our FDA and our country, you know, in the States, which you know about. And the world followed, you know, ICD, the process they had for coming up with these things was just a shadow of what the people they had working on, the DSM, and the money was a pittance that the World Health Organization had devoted to this. They had bigger things to worry about, you know, rather than psychiatric classification. So, you know, they pretty much followed us. The ICD allowed a lot of the way. That was the DSM folks. But, so it was good because we could then show that for panic disorder, which was, you know, our area, that was one of our big areas at the time, and Grophobia panic disorder, we have a psychological treatment that's at least as good as not better than our drug treatment. And the same thing for social anxiety, what depression, and then Tim Beck, you know, came in with a, one of the first clinical trials for depression. Very controversial, but, uh, it's another story, another angle, so I'm good. But, you know, it, it helped us to get our stuff out here. You know, we weren't just juniors, psychiatrists, that we weren't just projective testers who set off in a corner, you know, helping the psychiatrists figure out, you know, what was going on with the patient. You know, we actually had major intervention procedures developed based on psychological science that we had developed that, that were now based on the early data effective. Okay, so big advance, uh, for us, for us, and for the whole field, I think, but, particularly for psychology. So then, through past four, would ten years or so, by the late eighties, it seemed to me that when you look at the procedures, we develop for these different disorders, be it OCD, or Pantisort or Depression, or even, you know, PTSD was just originated in 1998. So things were just starting with PTSD. But that was controversial. People said, no, that's, we don't need a disorder to describe that, that's not a disorder. Anyway, that's another story. So the, the, when you look at these treatments that seem to be successful right the way along, it seemed to me, you know, I'll share pretty much the same components. You know, number one, you look in emotion. Number two, you look at their reaction to this emotion in context, whether it be a specific foldable, let's say, flying on a plane, or, you know, a panic attack that was debilitating, and we'll cause the emergency room, or OCD, you know, where you have an intrusive thought, that was unacceptable, and if I had to be suppressed at all costs because of provoked, extreme anxiety, you know, in all of these cases, what we do in our CBT approaches is we evoke the emotion using the triggers that are individual to the patient. We lead them through some exposure, actually, we do some cognitive training, you know, we do some vacuum approaches. You know, what's rational, what's irrational, you know, is, is that as dangerous as it seems? Let's look at the rationality of it, you know, the typical cognitive therapy. Let's test it, you know, what would be, what would happen if you actually went into the situation. We used to do, in those days, also some common procedures, either breathing or training or relaxation, leftover from the systematic desensitization days of Volpe, and then we would, you know, bring them out and do some, basically exposure procedures. Subficobia, that's simple enough, you know, you do some exposure to the phobic situation or object, the right approach, you can do that, approaching it. OCD, you know, you, you actually have them think the thought rather than suppress it. And at the same time, prevent their ritual, and that's been suppressing it, and therefore, you know, prolonging the and you change the way that you get the attributions and appraisals. So, so that was the late 80s, and we began developing, you know, by that time we had developed manuals for panicked disorder. Back at the developers manual for depression, we developed manual for panicked disorder and for GAD, and there were some others were beginning to appear. And they were targeted at these narrow slices of psychomythology. But with the notion that, you know, what we're doing is pretty much the same thing. By 1990 was so, I think I wrote a paper on this right around them, as well as a book that was published in A.E.A. Where we said, "Maybe the psychomythology really has a lot more in common." At least what we used to call neuroses. Maybe there's something to this, maybe there are some, some not the heavy theoretical baggage that Freud imagined, you know, when the war was in conflicts going on, you know. But maybe there are some common processes going on here across the psychomythology, where the individual variations of it that form our slices of psychomythology are not that important. Maybe not central. Maybe there's something, you know, sort of underlying it. And that brought us back to emotions, affect, and the emotion dysregulation. But all of these people were experiencing, along with their attempts to escape an avoid. You know, these intense emotions. And the whole construct of neuroticism, which was Isaac's construct initially. And he made pains to distinguish it from the construct of neuroses, some neuroticism. At the time he said, as I've written in some places, back in the 40s, and one of his first papers, he wrote, "You know, I don't like the name neuroticism, because it's too close to the term neurosis and it's too confusing. It'll confuse people." But it was the best he could do. He had some rationale for, you know, why he came down with that. So, one of what began thinking about this, and when, you know, in collaboration with some of my good colleagues over the years, Tim Brown, you know, Rick Zembarg, Shell Crask, Run Paint, could go on about that. Not only about the mayonnaise, but you know, some of my good research collaborates over the years. We began really looking at this. And it did seem that, you know, all of these manifestations, the thin slices of psychopathology, had more had some underlying themes. And one of them wanted to emotion dysregulation. The other one was, you know, sort of out of control, negative affect to which they reacted very badly by avoiding or escaping or otherwise finding it supremely aversive and doing anything they could to avoid or escape it. And the various other processes that contributed to this. So then by 2000 or so, so this is all a while doing our clinical trials. But by 2000 or so, we hit upon the notion that let's come up with one trans-diagnostic protocol that might be a lot that might be much easier to disseminate. Something that would be much more useful for the commission. And let's, and we came up with, again, during those years, some early conceptualizations of neuroticism being at the core of these non-psych-- these disorders. We were-- I was personally inspired to some extent by a British psychiatrist, named Chris Fairburn, who was eating disorder. God, that was what he specialized in. And he had come up in the '90s, and we used to talk quite a bit and see each other, all the different venues around the world. But he had come up with the fact that eating disorder, you know, using the DSM-3 concepts, they were like five eating disorders, a beling me of anorexia, binge eating disorder, and some variations of that. And he came up and said, "No, this is all the same stuff." You know, this is all really-- underligeness is a real phobic reaction to gain-- to be heavy, you know, and various escaping avoidance. And a real cognitive distortion of body size, you know, body shape, body size, almost like a body dysmorphic disorder, kinds of, you know, conception, and all the attempts to mitigate those strong emotions that in reaction to weight and body shape. And then all the consequences that occur because of it, you know, the real physical consequences of paying anorexic, and medications were solving sadly in death. But, so he came and he said, "We need one treat." So we need for eating disorders. He came up with his enhanced CBT treatment for eating disorders. So that was the transdiagnosis, but only across eating disorders. And then it seemed to me, you know, we can expand that. We can go across all the the old neurotic spectrum. And then we published the paper in nearly 2000s, you know, on the unified protocol, you know, by transdiagnostic protocol. And later on, we, you know, we published, and then with Tim Brown in the late 90s, we began publishing our kind of statistical approaches to isolating the common components of all these dysmorphic spectrum, you know, on coming up with, you know, high negative effect. For some disorders, low positive effect. That was less widespread, you know, but for depression, for social anxiety, and for agoraphobia, you know, they're also characterized by low positive effect. And the various attempts to escape in a boy, not necessarily the triggering context, whether it be a intrusive thought or a shopping mall for agoraphobia or whatever, you know, we downplay the importance of that and focused on the experience of the emotion itself on the emotion dysregulation itself on the unacceptable, very aversive experience of intense negative emotion. Or in some cases, positive emotion. And published some, you know, data showing, showing these kind of core elements. So with those core elements identified, and with the major one being sort of neuroticism, which is, you know, high consistent negative effect with, you know, continual sort of arousal, we decided that, you know, what needed to be treated was the high negative effect, the reactions to it, their multiple ways cognitively in behaviorally in a attempt to avoid or escape it. And that was really the birth of the protocol. So with that, by the 90s, then we began to say, yeah, the DSM-3 is really not the, this was an important way station, made some important contributions, but it doesn't reflect nature. As we say in the classification business, it doesn't cut nature at the joints. You know, it seems like it seems like the work that you were doing preceded some of the current, like the high top movement where they're, you know, it's really psychometricians, right? Like, to, and to, saying, hey, the way that just, it's very consistent with the story that I'm hearing you say. Yeah. Oh, yeah, it was way before the statistician got involved, you know, in a sophisticated way as they are now. I'm not entirely a fan of that, the sort of, let's say, unabashed statistical approach to organizing psychopathology. I think actually they miss a lot along the way. I don't think it says, clinically meaningful. It's not going to be as, as clinically meaningful as it could be. And that's another story. And, you know, I very much admire the efforts that they make. How would you, what would you think about doing differently or how to approach it? Anytime you do this, you know, sophisticated factor analyses and things like that, it was basically what they're doing. I've taken a whole bunch of questionnaires throwing them in a pile, seeing what goes together and coming up with, you know, the variety of these factors and profiles and things like that. But it's all still very normal, aesthetic, number one. You know, it all boils down to throwing everything in a pot and kind of sort of seeing what comes out now. But then you have to go back to the individual patient. They try to do this, they try to go back and get a little bit categorical by developing profiles. There's a profile, well, there's this profile, there's that profile, like St. Sato, hang together. But they're so normal, aesthetic that they don't often make a lot of clinical sense to me. And I'm not sure they're going to do really helpful to clinicians going forward. You know, the MNPI had all these profiles. And there was very empirically derived process. So, you know, I can dare to clearly assign to the process. But, you know, do you really see much of the MNPI these days? I don't think it really stood the test of time. You know, I think this is, I'm like, I'm being a bit harsh here, but I think basically we have a new MNPI. And I don't think it'll stand the test of time. So you've developed, that's all right, I'm open up. What's that? I'll kiss a lot of help for that. They say this, but my good colleagues in the high top field, one of them is a student in my lab, a postdoc in my lab at the time. But anyway, that's my opinion. So you developed this unified protocol, which is designed to sort of focus on manifestations of this underlying neuroticism. A question that I had is, you know, you have these different modules and the idea that every patient goes through all of these different modules. How do you do you think that the clinician working with the patient should sort of go through them uniformly, or do you think that they should be somewhat adapting them for the personalizing them? And if so, how to go about doing that? Yeah, well, that's, that's an excellent question. Right on the cutting edge of research. And although I'm not actively involved in branching with research anymore, many of my former proberies and former postdocs and students are, and that's exactly what they're working on. Because you know, these protocols are and ours is a protocol, even though it's transdiagnostic and coherent, and it's still a protocol. And it's never meant to be applied rigidly. I mean, that's why we all get clinically trained. It would meant to be applied rigidly, wouldn't it? Clinicians, you know, you'd be like, you just have an AI agent do it or something. But to back up a bit, for example, to support that, one of the problems we would have in our clinical trials was we would always be required to vary wisely when we're doing clinical trials. Make sure we had an independent variable, which would be the treatment procedure. Well, to do that, we'd have to develop these adherence and competence scales. It would be applied to every therapist. And it'd be somebody who would be responsible for adherence and competence in the trainings. They have to look at a sample of the videos of them delivering the treatment. Well, what we found really on was that we we were occasionally, and then we, you know, 20, 30 therapists involved in some of these large trials. What we discovered early on is that we would occasionally get these people who scored perfectly on adherence and front-done competence. We say, and we will just see the numbers. And this is what the hell is going on here? You know, and we maybe bring the radar in and look at everything. And what would happen is that these people will just reading the manuals. They were just reading the manuals. Well, almost no regard for, you know, personalizing it, doing the art of the clinical work, you know, and making sure that they're still applied to them, adjusting it to their contracts, their surroundings, their understandings, their their idioms. And the therapist would very incentivize to do this, some of them, because we're getting paid for it, you know, he was a, and they wanted to keep, you know, keep that, keep being therapist. For some of them, that was, you know, it was a motivation. I mean, they were good people, they were trying hard, but, and so these protocols were never meant to be, they're always meant to be personalized. Then it brings us to the old question, but how should they be personalized? What are the guidelines here? You can't just go out like, you know, the traditionalist in for all these years and say, go home and just form a good relationship. The best you can get the patient to like you at all. And I said, how, what are the guideposts for making these clinical decisions? Do the patients necessarily need all five of our core modules in the unified protocol? Maybe they don't need the motivational portion. So we're now developing, that we have developed actually, you know, some, or in the process of developing some, some assessment procedures, whereby we'll look at the various levels of skill. Marshall, let me hand the borderline, DBT people do this too. What are the skills, whether it be the cognitive kind of skills, the cognitive understanding and so on, the exposure? One of the kind of skills that these people already have that maybe we don't need to really work with them much on that, but we need to focus on when it's maybe there in a particular week. So let's say an area that's under heavy the number of grants in that area now. So that must be personalized skill. Because that was exactly the, because you have a motivation module. One of the things that I thought about is, you know, sometimes you have a patient who comes in, who's really motivated. Right. And then it was like, so then would you, how would you sort of make that determination? So it sounds like that works going on. Right. So, but in our lab already, clinically, people say, well, we just want to spend much time on that. Yep, this patient's good on that one. We'll move right on. Right. All right. So, you know, we do have a range of sessions for each of the five core modules. And that's sort of meant to accommodate the individual adaptations by the clinician. But we're trying to come up with something maybe a little more systematic. Right. Right. So I just have a couple more that I want to for before I let you go. Yeah. Sort of if I can just random things. When it comes to patients that don't improve, what do you think in terms of some of the most, the way, the potential ways forward for looking at treatment resistance or whatever you want to call it? What do you see as the most, you know, possible or exciting potential ways forward for helping these folks? Yeah. Well, that's an excellent question. And the subject of, you know, intensive research, solves it in a big topic in psychiatry. You know, psychiatry will go around giving workshops on treatment resistant patients. The usually solution is, okay, they do well in this job, or drug number two, here's drug number three, maybe drug number four, or maybe combined. You know, so that's the typical, oh, come on, that kind of workshop. In our case, you know, obviously depends on the, a careful analysis to meet in my mind, a careful analysis, behavioral analysis, so, you know, what's going on? And there's a lot of different reasons. And I think, you know, with a careful behavioral analysis, you can often come up with, with some adjustments that need to be made. I think, and I'll give you an example a minute, but unfortunately, this all hasn't been system applies very well yet. And I think this is something that very much needs to be done. So, you know, I had a patient once, who was a PhD in education, a really bright guy, and he had panic disorder. And we went through the whole written role in panic disorders, the disorder, one of the disorders with which we have the highest rate of success. It's fairly, which is not a whole bunch of comorbidity with it, you know, we can usually deal with that very well. This guy, in session, he would understand everything. He could spit it back, he could teach us, he could teach the next patient, you know, the concepts, but he wasn't getting better. I mean, you know, he used to, the funny thing was, he used to, he used to love the, the flats, you know, the tracks, the horse race, the horse racing. And he would go, and he was an excessive gamble, but he would go, nothing was more exciting than him, and watching this horse come, come in, you know, wind by his nose, and something, we go say, "Ballum Jack," and say, "Jack, what, what are you, what are you feeling?" He had to, "Oh, I feel just totally excitement." You know, and, "Yeah, heart rate is up, I might be perspiring, I might, you know, make sure I breath them so excited." And all that, "Jack, isn't that?" Just exactly what you told me you feel when you have a panic attack, you know. You know, why is this a good feeling, and it's not, you know, when you have your panic attack, and it makes you totally shut down, and he would understand that rationally. It was the old notion of, you know, to get the, the battle between the rational and the emotional, but when he was having one of these episodes in the context in which usually school, the negative thinking, you know, everything would come up. In his case, really, I found just trial and error, it really would just perseverance. I just kept, and then I found this number of patients. I just had to hammer him his home, example after example, and even rationally, he knew it, you know, he just needed more intensive treatment. This is one example. In another case, I had, it was a woman who severely, how spouted, and her story briefly was that, she had been married to a guy in New York City who turned out to be, and they lived very comfortably, you know, they had locked some money. But she never really knew what he did, how he made this money. You know, she never quite understood it, and he always put her off, you know, when she would inquire about it. Well, it turns out, let me call on the story short, it was a mobster. He was a mobster, and in the space of a couple of months, they got him, fun trial, went away for jail for decades. She was left with nothing, and she had no family to fall back on. So she went from this, you know, great lifestyle to being right almost almost. When, as luck would have it, she happened to meet a guy who became her white knight in shining armor, and they headed off, and he married her. He took, you know, some things in between. But shortly after that, he married her, basically rescued her, you know, and he went off to another city, his city where he lived, in New England. And so, years go by, a couple of, you know, several years go by, and she gets referred to us. She's housebound, you know, she's absolutely, you know, anxious and can't go out and housebound. And basically, again, make a very long story short. We treated her, nothing worked. Wouldn't bunch her. She was a very reasonable person. And once again, rationally, she understood everything. Nothing worked. And then it turned out her husband was a pretty controlling guy, right? So he's very nice. He never roses elevated. He was shouted. Never rose his voice. Nothing like that. But there was some rigid things she had to do. His mother had to come to dinner twice a week. Yes, that was what they always did. She had cooked a dinner. And he had other rituals, other things he had to do, was the house had to be a certain way, another bell. And all of these things would keep a kind of occupied. Anyway, so that's the context, which I'm leading into. So, then, again, the fates took hold. And this guy develops a aggressive cancer and up and dies in like two months. He was a young guy, you know, in his maybe early 50s. And of course, in all the promotion in the crisis, you know, I wasn't seeing her at this point. This is my patient. And next thing I know maybe five to six months later, I run into the person who had referred her in the first place. And I say, oh, whatever happened to Jane. So Jane, what happened to Jane? Is she okay? I'm terrible. I don't know what her husband died. And this friend said, it's the most amazing thing. She inherited a lot of money. You know, she, this will. And she seemed to get better. And she was out in a boat. And then she picked up and moved back to New York. And rather than flat, she seems to be fine. So I don't know what happened. So yeah, there's nothing I did. You know, what happened was, turned out to be some dynamics, you know, some marital dynamics going on there, where she had lost all control over her life. But old this guy, this night and shining armor, so so overwhelmingly in depth to him for rescuing her that she could not object. She could not bring herself to say, no, I really don't want to see your mother twice every week. I didn't like you. I don't like your mother. No, no, I'd really rather go out and do some of my own things. He wouldn't let her, he was extraordinarily controlling. And but she was unable to, you know, bring herself to deal with it. So in that case, the agoraphobia was sort of the called pseudo-virror, whatever it was, but it seemed to be a function. So you could say, well, that's a sub-dynamic sort of thing. Well, you could say you could do a good behavioral analysis, you know, and see that, you know, sometimes you get these, there are a number of cases like this, you know, where you get these, the sort of anomalies, you get these treatment resistant cases. In my experience, you know, a lot of them are different. And, you know, there's still a ways to go to sort of untangle maybe how we could teach clinicians to systematically evaluate these things better. But there's another example of, you know, you can't just do a manual and you have to be ready for, we know that 70% of the people, 70% of the people, 70% of them do well. You know, how do those people will be pretty much cured. The others will do very well. They're really functioning much further. 30% will either not be doing that well. It might have improved a little bit or not doing well at all, or in some cases, they're better worse. Occasionally, you know, we see that. And you know, you have to sit down. You know, never go about, I tell my students, never go about persevere. Get in there, you're missing something. And get in there and do the analysis. Try a different direction, you know, and keep working with the patients. Don't you say, well, to that, you know, good luck with the next therapist. Well, that optimistic point, before I let you go, I did, I mean, you've written so much. You're so prolific. But for listeners, if we wanted to point them to a handful of resources to sort of like learn more about your work, what would be like the handful, you know, the couple that you might suggest, and I can put those in the show notes that way people can go jump to them. Sure, could I just send you two or three articles? Of course. I would choose. Yeah, I'll just do that. That'd be absolutely wonderful. Yeah, I'll send you a couple of. Okay, that'd be great. Dr. Rowe, this has been, I'm sorry, go ahead. Yeah, one for the unified protocol, maybe one for the riders of, yeah, that'd be great. That'd be great. Well, I can't tell you how much of a thrill this has been, yeah, I just so appreciate you being generous with your time. It's been wonderful. I'm talking with you then. Yeah, that's the, I never had a problem with talking with my students. Hey, that's a wrap on our conversation. As I noted at the top of the show, be much appreciated if you spread the word to anyone else who you think might enjoy it. Until next time.[Music]