Protocolo Unificado para el Tratamiento Transdiagnóstico de los Trastornos Emocionales, con Dr. David Barlow I Episodio 81

recording. So here's nothing. Hello everyone and welcome to the podcast. Today I have the pleasure of speaking with one of the most influential figures in clinical psychology, Professor David Barlow, had changed the way many of us understand anxiety, emotion, and psychological remains. One thing that has always impressed me about your other work is the versatility of the unified protocol and how it can be applied to very different human situations. In my case I am currently doing my PhD on the online application of the unified protocol for people understand undergoing fertility treatments. And it's fascinating to see how similar emotional process appears in different situations that seems very different on surface. So today I would love to talk with you about emotions, suffering, therapeutic change, and the future of clinical psychology. Professor David Barlow, thank you so much for being here. It's my pleasure to be here and speak with you today. For many years in psychology, one psychology focus on separate diagnosis and different disorders, but your work helped me to change this idea. What were you seeing in clinical psychology in clinical practice that did not fit well with the traditional diagnostic model? Well that's a very good question. I began noticing really 40 years ago that many of the disorders we were seeing that were so caused so much suffering in people were very very similar in many ways. So I remember first thinking about this back in maybe the 1980s when I would see a one patient with a specific phobia, you know very straightforward phobia of let's say small animals like dogs. Some people are very phobia of dogs and do everything that can to avoid dogs. So they say a dog, that dog or even a picture of a dog for very severe cases. And that dog of oak's sudden anxiety in some cases panic, they do everything they can to avoid or escape the dog walk away around the dog more far away, sometimes run away or not even in some cases look at pictures of dogs. More common with things like snakes and spiders, but you know there's a lot of people phobic of snakes and spiders. And then when they're able to escape the situation or avoid the situation they feel much better because the phobic object is no longer there. But then I would see a patient with for example obsessive compulsive disorders. And they would report to me, you know, during the interview that they have these terrible intrusive thoughts. And a very common one in young women, young particularly young mothers, is a thought that somehow when they're holding their baby or their young toddler to child, they love very much. They're going to hurt him. They're going to hurt him or even something horrific like killing them. Now it's the last thing they would do. But that thought evokes terrible anxiety and panic in some people. Some people are able to say, oh that's a terrible thought, but my god, I don't know where that came from. I'll just ignore it. I won't think about it again. But for other people, the folks very severe anxiety and panic. And they do everything they can to suppress it or avoid the thought. We'll get rid of it somehow. And if they're successful by distracting themselves or using some other rituals, such as compulsions, then they feel better and they go on until they have the thought again. Well, it occurred to me at one point. You know, these are really the same processes. There's a trigger that causes intense anxiety or panic or some strong emotion. The person who's who is affected by this trigger does everything they can to suppress it or avoid it. Then they feel better and it's a cycle. And because they avoid it and repress it and feel better, it reinforces the whole process. And so, you know, just seem to me, it's the same process. And maybe there are some underlying common factors here that we could focus on, rather than simply the picture of the dog or the experience of the unwanted thought. And how does this idea later become the unified further one? Well, then, of course, we began as our research progressed, our research, the research from others. We noticed two things. First, very few people presented with just one disorder. Most people had a number of anxiety or depressive disorders or dissociative disorders. So that's a process we call co-morbidity. You know, the presentation of more than one disorder. Well, for years, we used to choose the most severe disorder, the one that was bothering the patient the most. And we treat that. Maybe panic disorder, maybe OCD, maybe depression. And we just treat that. And then we see what was left. And if there were other things still remaining, then we'd go and treat those. So again, we thought, well, if there's, you know, if what's driving these disorders is basically the same process, maybe we can just treat the underlying process. And that would be a lot more efficient. At the same time, we began looking at this underlying process. And the big question there was why do some people develop emotional disorders, either depressive disorders, and others don't? It's many people experience the same kinds of stressful situations in their lives in a personal or traumatic or or social. But only some go on to develop emotional disorders. So what is it that characterizes these people? And as we look further, it's seen that the common factor among all of these people was a personality dimension that we call neuroticism. And neuroticism was a partly inherited tendency to experience very very strong emotion when confronted with some kind of a stressor that we know everybody confronts stressors almost every day. But for people with this personality dimension, they develop very strong emotional reactions to the stressor. And they feel that this emotional reaction and the context and what it occurs is out of their control. It's uncontrollable, unpredictable. And that basic sense of uncontrollability combined with the tendency to be emotional, to experience strong emotions, seems to characterize the personality dimension of neuroticism. And the fact that it's appraised as being uncontrollable, there's a very negative connotation to that. Some terrible, I'm not going to be able to control this situation, and some terrible things might happen as a result of it. I don't know what they are, but I can just tell something very bad is going to happen to me. And so is that negative appraisal, strong emotion, feelings of uncontrollability that characterizes all of the emotional disorders. So when we developed a treatment, we felt we had to include components that were directed at that basic personality dimension. That's so interesting. And in this slide, today, the unified protocol is used all over the world. But when you first developed the model, okay, did you imagine it would be eventually how such and learned impact involved research and clinical psychology? No, actually not at all. You know, many of us in my era, which was the early days of behavior therapy and cognitive behavior therapy. And this was an era where we were developing, you know, new approaches to problems. Up until then, the prevailing approach had been psychoanalytic, psycho dynamic, and it was, you know, supported psychotherapy and things like that. So when we began developing our treatments, they were much more structured and much more specific, much more focused on the problem at hand. And so a lot of us were doing that. So, you know, I'm surprised every day when I get, when I see articles appearing from around the world, you know, studying the unified protocol or people like yourself from before, you know, very interested in learning more about it. Now, surprises me every day that, you know, this could happen. This could have the impact that it seems to have. Mm-hmm. And one thing that I find especially interesting about your word is that similar emotional processes appear in many very different situations. In fertility, for example, we see uncertainty, fear, hyperveiling events will be an experience, an emotional experience. But do you think this is word transdiagnostic approach become more useful? Yes, I think what happens is this dimension of personality neuroticism is very widely spread. And it doesn't in itself mean somebody has a disorder or is suffering from a severe problem. It's just a personality dimension. But it can interact with any adversity or stressful situation that we might experience. So, and again, two people might be faced with the same situation, such as, you know, having a panic attack or dealing with infertility in the case of women or perhaps experience insomnia. And one of them may go on to develop a disorder and the other won't. There are some other examples too. So, I'm going to take insomnia for example. As we all know, there are people for whom sleep disorders including insomnia becomes a major problem. But yet, we know that all of us, particularly as you get older, maybe not you, you might be too young. But most of us, as we get older, have experience with difficulty sleeping at one point or another. We'll wake up in the middle of the night or we'll wake up too early or won't be able to get to sleep. But mostly waking up in the middle of the night. And a person who does not suffer from the kind of personality dimension of neuroticism might say to themselves, "Oh, that's having trouble getting to sleep tonight, but I'll get back to sleep eventually." And I'll be alright and I'm actually even more tomorrow night. But the person with a, in other words, it implies, "Well, I can cope with this. This is not, this is not terrible. This is not uncontrollable." But the person who tends to be, have experience neuroticism, they might say, "Oh my God, I can't get to sleep. I've got a big test tomorrow morning. If I don't get to sleep now, I'm gonna flunk that test and or do very poorly at work. And I've got to get to sleep right away." Well, in struggling with it, of course, they make it even more difficult to get to sleep. And the process cycles like that. So here's two people experiencing the same problem, sleeplessness or difficulty sleeping. One of them, it develops into a severe problem, you know, and they engage in all kinds of behavior to try to prevent it from happening, which usually works against them. The other one feels like, "Well, this is not, this is not too bad. I can handle this. I'll deal with this." And so it would be the same with fertility issues, you know? It's a very stressful situation, dealing with infertility, depending on the course of action in vitro fertilization or whatever the course of action one takes. But if people are prepared to cope with it and say, "I have the resilience to cope with this." And yes, the injections are painful, but I can tolerate the pain. And something really good will happen as a result of it. You know, it becomes a much less stressful situation and they're more likely to go through it as compared to someone with a, you know, similarly, the mention of neuroticism, who would be very, very, you know, strongly emotionally involved. They make it more difficult for the procedures to proceed. But as you, as you were talking, I, I, I, I don't know if I'm going to just click to translate what I want to say, but I, I'm going to try again. As, as you were talking, I, I think that not only people who are neurotic develop disorder. So, or it's one factor, no? Because, you know, learn your history, also with neurotic, goes to a disorder, no? I know it's big. So, yeah, what, what, what, you're talking about the history that, yeah, that I, not only people who are neurotic develop a disorder, or do you think that a neuroticism is a, one thing that it's crucial to develop a disorder there? Well, I think we're talking about the relationship between neuroticism and the development of disorders. Yeah. Yeah. And there are many people who, you know, neuroticism like any personality dimension extroverts. There's other personality dimensions. They all are on a continuum. So it's not like you have it or you don't. And when we think about the cause or the ideology of emotional disorders, we think about what's called, and I'm sure you've studied it in psychology, called the stress diaphysis model. Does that ring a bell, the stress diaphysis model? So you have a certain level of a personality dimension, such as neuroticism. The higher you are on that dimension, the less stress is needed to possibly trigger a disorder. On the other hand, if people experience very severe stressors, so people have studied, for example, soldiers who are prisoners of war, who experience terrible suffering, butcher, isolation. And if it's severe enough, almost everybody will develop, in this case, a post-traumatic stress disorder. Although there's still some who don't. You know, at that very high end of being resilient, you know, there are some who experience unbearable, seemingly unbearable, from and don't develop a disorder, but they're, you know, the example we use for people in the other end of the dimension, you know, many of us have pets. And pets, like every other living thing, die. And when your pet dies, your pet will be a dog. And for most people, it's never sad, but you know, and for a couple of days, they miss the dog, but after a couple of days are alright, maybe they'll get another one, maybe not. But for some people who have a very strong vulnerability, they can develop severe PTSD over the death of their cat. So, and most people wouldn't understand that. You know, why would they be so? They must not really love that cat, but even so, why would you be incapacitated for months at a time afterwards, and be unable to work or carry on with your life because your cat died? So, you know, that's sort of thing. And we're all individuals. We all have different levels of vulnerabilities. We're affected in different ways by stressors. And part of our job as psychologists is, of course, to focus on the individual and try to sort out, you know, just what these relationships are and how we can best help. And that connects with another very important idea in your world that often the problem is not the museum, but how we respond to it. And so, in this slide, what do you think we still misunderstand about emotional revelation? About emotional avoidance? Yeah. Well, emotional revelation, yes. Yeah. Well, this one of the aspects of the unified protocol is that up until the U.P. is recalled, the unified protocol, and related trans-diagnostic protocols. You know, we would focus more on the trigger of the emotional disorder. So, if it were PTSD, we'd focus on the trauma. Yeah. It's a specific trauma. If it were obsessive-compulsive disorder, we'd focus on the intrusive thoughts, and they might be contamination, or they might be, you know, overly religious intrusive thoughts about good and evil. And so, we tend to focus on the, you know, the trigger. We call it the trigger. Not the cause, but it's the trigger. The precipitating stressful event. With the unified protocol, we began to realize that that's a relatively trivial part of it. We need to focus directly on the emotion. It's the strong emotion itself that is causing the problem, and that is what all the patients are avoiding. They, without that very strong emotional response, they wouldn't be so disturbed about seeing a spider or a snake, or maybe having, you know, a terrible thought. The problem is their reaction to it. They're strong emotional reaction. And so, you know, then we tried to determine, well, why do they keep behaving that way? Particularly since, by definition, they know there's no real harm. And let's say seeing a spider across the room or thinking a thought, or they've learned at least that, you know, the actual danger of flying in a plane. The actual danger, the probability of something that happens very, very low in this field. But yet, even though rationally, they know that emotionally, they can't stop themselves from continuing to run away or avoid it or suppress it or dampen it. And so, we began focusing on the ways they're dealing and experiencing the emotion itself. So that became a big difference. Also, after so many years, research and psychological treatments, by imagine your understanding of the ability to change has also evolved. So what do you believe? Grace the deepest change in therapy. The deepest change. I don't know if I am explaining what. Just like the best mechanism of change. Yeah, the change, the best change. So. Yeah, in terms of. We just finished revising. The manual for the unified protocol. So you probably have the second edition, second edition. Now we have the third edition. It's just been finished. So it'll be out next year. But what we really focus on there is. We used to call it emotion exposure. So how can we help our patients experience the emotion? Which you've had experience with. You know, provoking the emotion in treatment. And. Accepting the emotional experience for what it is. Now we call it emotion approach. So instead of avoiding the emotional experience, we call it approaching the emotion. So again, at the heart of treatment is our procedures. To try to get. Our patients to. Experience. And cope differently. With this emotional experience and be accepting. And. And removing the various. Collative and behavioral. as they've been using tool to escape or avoid the emotion. So we think that's at the very heart of the treatment. That's what we try to do with all our patients. And in so doing, I don't know if you study cycle and lytic therapy at all. Maybe they don't teach that any more, but they don't need to stay. Actually, there are some similarities with the lytic cycle therapy. If you strip away all the theoretical factors, which of psychoanalysis, what happens in psychoanalysis often is that you are trying to encourage a process called catharsis. So catharsis basically means getting to the root of the emotional experience, experiencing it fully and letting it all out, letting it really come out. And in psychoanalysis, the theory is that the conflicts that had been causing these strong emotions are too evident and too negative to admit into consciousness, so they become unconscious. And they're suppressed and hidden, but the treatment would be to help people experience these emotions more fully. But in psychoanalysis, it would take years to get the line of coach and free associate. And three years later, maybe something better would happen. So it wasn't really structured in a way that allowed this to happen. But basically, the principle is very similar. A lot of my colleagues from a more psycho dynamic point of view sort of recognized that process. Yeah, sir. I have another question that is, if you redesigned UNIFI further today from SCARTS, will you add any new skill or change anything important? Yes, actually. Uh-huh. So in the third edition and the brand new third edition, we now specifically added procedures to deal with positive effect. And yeah, sir, yeah. So up until now, we've been dealing really just with negative effect, anxiety, panic, depression, sadness. But we also know this research from our research and some of our colleagues like Michelle Krass and others that people with emotional disorders not only avoid or suppress negative effect, negative emotions, but also positive emotions. And obviously, this contributes even more to their inability to enjoy life and function well in life. So there are many people who tend to dampen these emotions because they feel they don't really deserve it. You know, there are others who feel that the intense positive emotion in some ways is just as scary as a negative emotion. So we have, for many decades, we've had patients with, like, panic disorder, who, if they're loved ones, their family were coming for a visit, say, maybe they were flying in to the airport. They wouldn't go to the airport to meet them because they would be, they would, they would, we would discover when saying, why would we not? Go to the airport and reach your son coming home, you know, when your daughter and, you know, and give them a big hug, and you know, that's such a happy occasion. They would say, oh, but I would be afraid I'd lose control of my emotions, you know, and maybe my heart would speed up and I might have a panic attack or a heart attack. So, you know, again, they're afraid of their emotions, but they're also afraid of their positive emotions. Now we have introduced, we've adapted our procedures so that they actually, we provoke positive emotions as well because they, there's so much, you know, avoidance of these positive emotions and they have such a difficult time experience positive emotion. We introduced procedures to help them increase their positive emotions, things like savoring, you know, savoring the moment, savoring this, learning to, you know, get every bit of enjoyment out of it and, you know, thinking more positively about the event and other methods really getting out there and doing things that would, that would, you know, put them in contact with having a lot of positive emotions, behavioral activation, so, so that's new. And that has become part of the unified protocol. - Mm-hmm, interesting. And, well, you know, clinical psychology is also thinking very quickly. What concerns new emotions and what excites you most about the future of clinical psychology? - Well, I think there's, you know, a great future ahead for people like yourself studying clinical psychology. There's the biggest, the most exciting thing is that we can really help a lot of people, though. - Yeah. - You know, we don't know everything. We can't help everybody yet, but we can help a large number of people and really relieve their suffering and kind of enhance their, their function. But there's so many tens of millions of people who experience these disorders. And there's still very few mental health professionals that the biggest problem is the things that concerns me the most is, how can we scale up our treatments so that they reach a larger number of people? - Mm-hmm. - How can we better disseminate, you know, our treatments? And as you know, because your mentor is working on some of these issues along with his team. So we're trying a lot of different ways, seeing people in larger groups going to the internet and doing digital kinds of treatments, you know, web-based interactive treatments. How can we, you know, bring these procedures out to reach more people? And there's so much more work to be done in that area. In many ways, that's a more difficult problem to address and try to solve than developing the treatment to begin with, you know, which can develop the treatment. And there it is, but it's not going to do any good if people won't get it. - Now, when I ask Jorge in the same interview as I'm doing to you, what message will you give to the new generations? As you say, you say exactly the incredible number of people we are able to. help to grow these professions, you say the same. Well, that's very interesting, you know? Tell them I have some way to agree with them. Well, before we finish, okay, I would love to ask you something a bit more personal, okay? After a lifetime study in anxiety, emotions, human suffering, what do you have you learn about the way human beings deal with emotional pain? Yes, I think we've all learned that as humans, it's a fundamental kind of law of nature, you know, that we seek out what is to our advantage and we avoid or try to escape what is painful or to our disadvantage. So it's, you know, just a psychology, the fundamental law of effect and that's what it was called traditionally and sometimes all of our lives are a collection of experiences, some of them positive, some of them negative, it's the human condition to suffer on occasion, to feel pain, to suffer, to be disappointed, to be stressed. And so at a very basic level, obviously don't want people to start enjoying it, it's nobody is going to enjoy it but emotions are very important to us, both negative and positive emotions. They help us adapt to life, negative emotions, you know, being anxious helps us prepare for possible threats in the future, being panicking of faithful helps us to escape a immediately dangerous situation, being depressed, makes us, you know, withdraw and reappraise and feel, you know, how can we best deal with these future events? So all of these emotions are very useful, very adaptive, very helpful, they're part of our, of our being, but they can get out of control like anything else in life. And people will experience pain and suffering because that's a human condition. We lose things, people die, we lose love, we get injured, we get hurt, we get killed. So in a very basic level, we're trying to, you know, a useful thing in the future would be to teach kids even in school, how best to deal, you know, with negative emotions, with pain and suffering, and not to try to hide, run away and hide in a corner or run to, you can't always run to your mother, you get a big hug, you know, a lot of people are feeling it, very useful to have a course in dealing with pain and sadness and negative emotions in the school system as a way perhaps to prevent the development of emotional disorders later on. And finally, I want to ask you three short questions that I ask everyone who comes on the podcast. And the first one is, if there is one person you will recommend for the podcast, someone you think will be especially interesting to interview or do you like, what will it be? There's many, you know, truly, you know, excellent people, if it would be very hard to choose just one, but I think that, you know, one person who is truly doing some excellent work, particularly on the new focus on positive affect is Professor Michelle Crask at UCLA, and she's doing some, she's doing really some very innovative things and it would be very interesting to get, you know, her opinion on things. I would say, I think that you will want one, one going to say, Steven Fates. Another question is especially for psychology students and young clinical, clinical technicians listen to us. If you could give one piece of advice to people who are just being in a clinical psychology, what would it be? What I always tell my students and their careers and their life is that first of all, follow your heart, follow the career that really interests you. And psychology is a fascinating career, but also one of the most important qualities. I think that, I mean, is it associated with having a successful career is perseverance. Yeah. Perseverance never give up, you know, if you write an article and it gets turned down once, revise it and re-submit it, it was turned down again, revise it and re-submit it, don't just say, oh, I'm done with that, you know, they don't like my work. Keep after it, persevere, persevere goals, and the people who do so many of them not only end up succeeding, but succeeding, you know, doing extremely well. So don't be frustrated or disappointed, persevere. I think that is crucial, yeah. And the last one, if you could go back to the beginning of your career in psychology, what message or advice would you give to your younger self? Well, when I was starting out, my whole world was revolved around psychology and psychiatry, mental health professions, all were revolved around psychoanalysis. But I had a mentor who said, maybe there's a different way, and so I followed that way. But as I did, I thought, am I crazy? You know, I mean, everyone else is doing this. Am I crazy going down this road? It turns out that, you know, by being true to myself and trying to do what I thought was right, rather than what other people thought was right, it worked out very well. I would give the same advice to any student coming along, you know, do what really seems to be the right thing to do, to you personally. Very important. So Professor Vallo, this has truly been a privilege and thank you not only for this conversation, but also for all your work you have done throughout your career. Your work has deeply influenced the way many clinicians and understand emotions and psychological training. So thank you so much. Well, thank you very much for having me, Alicia's been a pleasure to speak with you.