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The Future of Therapy: A Unified Treatment Approach

Is therapy moving in a new direction?

From the very beginning, clinical psychology has been characterized by a diversity of approaches. The field has seen continuous debates between theorists, competing schools of thought, contradictory bodies of empirical knowledge, and an ever-expanding roster of therapeutic techniques. This is not a bad thing. In fact, it is a sign of vitality. But while diversity and divergence are important, so are consensus and convergence. A field that splinters and divides constantly may devolve into incoherence. And a focus on competition may obscure the potential benefits of cooperation.

A rare example of a push towards cooperation and integration may be gaining steam as we speak. It's an effort to establish one unified treatment protocol for a whole family of emotional disorders (primarily mood and anxiety disorders). The benefits for the field of clinical psychology--and for therapy patients--would be potentially very significant. Instead of wasting precious time mastering and then applying an ever-increasing roster of specific techniques for specific disroders, therapists could treat a broad range of patients with the same general protocol, without sacrificing effectiveness.

The main champion of this potential shift is the psychologist David Barlow. Barlow was one of the most influential players in the last big shift taken by the field of clinical psychology--from the vague, loosely managed and idiosyncratic work of the psychodynamic therapies influenced by Freud and his followers, to the short term, focused, empirically validated treatment protocols that characterize the Cognitive Behavioral Therapy (CBT) approach.

Nearing retirement, Barlow is looking ahead to the next revolution. I, for one, like what he's seeing.

But first, a bit of history. Cognitive and behavioral therapies emerged in the 1960s as part of a growing effort at the time to bring therapy more firmly under the umbrella of science. Treatments derived from Behavior Theory (in particular Wolpe's systematic desensitization method for the treatment of phobia) and Cognitive Theory (mainly Albert Ellis's rational emotive approach and Aaron Beck's work on depression) were at first developed separately. But by the 80s and 90s, cognitive and behavioral treatment elements were combined to form CBT, based largely on the work of Arnold Lazarus, David Barlow, and David Clark. CBT protocols have since been developed for various disorders, including anxiety, mood, eating, addiction and personality disorders.

CBT came to rule the mainstream therapy landscape in the US, in part because insurance companies liked its short duration and focus on empirical validation. Clinicians and patients liked it too: they appreciated the sound results it often delivered. However, over time, the bloom started to fade, as it always does. Research has shown fairly high rates of treatment failure and relapse with CBT (although still usually lower than failure and relapse rates for medication treatment). In addition, the field has splintered, producing too many specific protocols for specific disorders. These protocols can be costly and time consuming to master, increasing the burden on already burdened front line therapists.

Finally, recent advancements in theory and research (mainly based on the work of Steven Hayes and his colleagues) have argued that CBT, which focuses on thoughts and behaviors, tends to neglect the role of emotion in psychopathology. Adherents of the so-called ‘third wave' of CBT therapies have even been advocating, quite adamantly in some cases, that the bedrock cognitive therapy focus on changing patients' distorted thinking should be abandoned altogether in favor of techniques that foster emotional acceptance and values-based behavior. In other words, instead of teaching patients to challenge and refute their negative or distorted thoughts, third wave approaches strive to teach them to observe and accept difficult emotions without becoming engulfed by them.

Anticipating a brewing battle, David Barlow has proposed a different option: Integration. Summarizing research results from the last several decades, Barlow has argued that different emotional disorders appear to share a ‘common latent structure,' as shown by several findings. First, he points to the high co-morbidity rates for different disorders (when two or more problems tend to happen together). Most patients nowadays are diagnosed with several disorders, and the symptoms of these separate disorders overlap significantly. Second, he points to the finding that a single psychotropic medication often works well for many different psychological disorders. Likewise, many CBT protocols aimed at addressing one specific disorder end up alleviating others as well.

Barlow sees all this as evidence that psychological disorders share an underlying structure. This structure, he suggests, is made up of three vulnerabilities:

1) a generalized biological vulnerability, which consists of a genetically-informed temperamental inclination toward neuroticism and behavioral inhibition;

2) generalized psychological vulnerability, which--as early life experiences interact with biological vulnerabilities--create a volatile psychological landscape manifested often in a feeling of lack of control;

3) specific psychological vulnerability, which relates to the specific focus, or expression, of stress and anxiety and hence to a particular diagnosis (e.g.: fear of rejection = Social Phobia; fear of physiological arousal = Panic Disorder; fear of bad thoughts = Obsessive Compulsive Disorder (OCD)).

In Barlow's model, when vulnerabilities ‘line up' and are activated by current stress, a disorder emerges.

Barlow suggests that disorders emerging from this ‘common latent structure' share common features, and therefore can be treated with a common set of therapy procedures. Reviewing the therapy protocols shown to be effective with a variety of related disorders, he concludes that the new approach should include four therapy components:

1. Psycho-education/boosting motivation (increasing self knowledge and becoming a partner in therapy)
2. Cognitive reappraisal (learning to think accurately about your thinking)
3. Preventing emotional avoidance (accepting emotional experience and increasing emotional literacy)
4. Changing behavioral habits in the context of exposure treatment (facing fears and learning new habits)

Let's review these components in some detail:

Psycho-education (More in a future post)
The key assumption underlying this treatment component is that knowledge is power. Much like medical patients, most psychological therapy patients are ill-informed about their condition. Psycho-education, as an initial part of therapy, aims to make patients active participants in their healing process. Typically, patients are educated about the parameters of therapist-patient relationship, about the structure and parameters of treatment, about psychopathology in general, and about their specific disorder. This initial phase is also used for the all-important task of building rapport--a therapeutic alliance--which has been shown again and again to be the strongest predictor of therapy success.

Cognitive Reappraisal (See my post, For Sound Mental Health, Think Again About Your Thinking)
The key assumption of this treatment component is that thoughts produce feelings and actions. Anxiety and depression-producing thoughts are often habitual and, as such, automatic. But these cognitive habits are learned, and therefore can be unlearned. Generally, patients are taught the process of critical thinking: they are instructed to identify negative, irrational thoughts; they learn to treat these thoughts as hypotheses, not facts, and then generate alternatives, evaluating the evidence for each alternative, and selecting the thought most supported by logic and sound data.

Common cognitive errors that are often seen in patients across many disorders are: overestimation ("It is very likely to happen"); catastrophizing ("It is absolutely terrible"); all-or-nothing ("Either I'm perfect or I'm worthless"), and overgeneralization ("I always fail"). When a patient learns to identify these thinking errors, he or she can more easily substitute healthy, helpful thoughts and ideas. (See also, Framing: Your most important and least recognized daily mental activity)

Emotion Regulation (See, Emotional acceptance: why feeling bad is good)
Research has shown that regulating emotional experience is a major developmental and psychological requirement. The successful movement from childhood to adulthood requires a person to learn to plan ahead, tolerate negative emotions, and inhibit impulsive behavior. Emotional disorders often represent the adoption of ineffective strategies for the task. Specifically, much psychological suffering is linked to the attempt to suppress, avoid or deny difficult emotional experiences. Avoidance fails in the long run, because it narrows one's life horizons. Many worthy paths are difficult ones. Attempts to avoid negative emotion are inherently futile and lead to an increase in the emotion one tries to avoid. Avoidance also hinders the acquisition of skills. You can't learn to do something by not doing it. The solution is emotional acceptance. Emotions are an important source of information, but not the only one and not necessarily the best one on which to base behavior. You may not be able to help how you feel, but you're always able to choose whether and how to act on the feeling. The patient is taught to accept the discomfort and chose their behavior based on their goals and values.

Changing Behavioral Habits (See, Action Creates Emotion)

Research in the behaviorist tradition has fairly convincingly shown that the best way to change emotions is to change the behaviors associated with them. "The individual learns to act his way into a new way of feeling" (Izard, 1971). In therapy, this principle is applied in several ways. One is through behavioral activation, which guides depressed patients to practice behaviors that are known to induce mood improvements (exercise, social activity) and/or are specifically associated in the patients' minds with positive mood. The other is through exposure therapy, which teaches the patient to confront their fears rather than avoid or escape them. This technique works because it works simultaneously on various levels. First, facing your fear leads to physical habituation. As we habituate to a situation or object, our heightened nervous system activity subsides and, concurrently, our level of discomfort goes down. Second, exposure improves behavioral skill, because it involves practice of what has been previously avoided. With skill come confidence, success, and esteem. Third, exposure leads to a feeling of psychological empowerment, because we feel good when we face and surmount an obstacle.

Finally, when we behave in ways that face and accept our emotional experience, we acquire emotional literacy; we learn how to navigate and thrive in the terrain. We learn to respond in ways that work. (See, Overcoming fear: The only way out is through)

In sum, Barlow argues, the best way to help patients, regardless of a specific diagnosis, is to educate them and establish rapport, to train them to think critically and accurately, train them to accept the full range of emotional experience, and teach them to change their behavior--through exposure--as a way to habituate to fear, acquire skill, boost confidence, and improve mood.

Clearly, the unified approach will not replace the need for therapists to get to know their patients and adjust the application of therapy components to the specific temperaments, needs, and symptoms of specific patients. Such individual attention, however, is likely to be more beneficial and effective if applied within the bounds of a coherent, unified therapeutic framework.

Barlow and his group are currently conducting several studies of this unified protocol and its effectiveness. I predict the results will be positive. And if so, I hope the field of psychotherapy will take heed.