Routine Outcome Monitoring (ROM) is gaining traction in psychotherapy and psychological treatments. Session-by-session monitoring with multi-item self-report questionnaires is also one of the cornerstones of the influential Improving Access to Psychological Therapies (IAPT) -program in Britain. There is promise that routinely measuring helps identify cases where therapy is “off-track” and can help larger service providers improve their outcomes. However, self-report measures also have known problems. What risks need to be navigated as measuring becomes widespread? Can these outcome measures be misleading for certain patient groups? How long will questionnaires be the norm and what role might smart watches, AI and the tech giants play in the future? In this episode, we discuss outcome measurement with Dr. Chris Evans. He is co-author of the book Outcome measures and evaluation in counselling and psychotherapy and one of the main developers of the widely used Clinical Outcomes in Routine Evaluation (CORE) system of outcome measures. Timestamps 0:00 Pros and cons of using multi-item self-report questionnaires 9:26 Which patients does routine outcome measuring work for 15:40 Intuiting what you are expected to answer 19:15 A systemic bias and lack of research into the limitations of our methods 25:50 Identifying “off-tack” cases 31:40 The future: Where will we go from self-report questionnaires? 38:15 Need for data on returning patients vs. confidentiality 42:19 Using new technologies, bodily reactions, AI and multidisciplinary research 47:44 The IAPT model and it’s broader effects 53:50 The industrialization of therapy and therapy research Related episodes on What's Next in Mental Health? : The Science of Personalizing Psychological Treatments (with Dr. John Norcross) Bruce Wampold - Moving Beyond Comparing Psychotherapies Should We Stop Prescribing Antidepressants for Depression? (with Prof. Joanna Moncrieff)

About a decade ago, one of the most influential psychiatrists of our time, started speaking out against over-medicalization and vested interests corroding the diagnostic system in psychiatry - a system he had helped pioneer. Professor Emeritus Allen Frances points to systemic biases with specialists pushing to expand their own speciality. Dr. Frances has protested about the pharmaceutical industry capitalizing on this expansion and suggested that the exceptionally lucrative Diagnostic and Statistical Manual (DSM) be taken entirely out of the hands of the American Psychiatric Association. He also doesn’t see the World Health Organization’s corresponding system working any better. In this episode, we discuss with Dr. Frances, how the field of mental health became so medicalized and how the two diagnostic systems are produced. We look at why specialists can be problematic evaluators when it comes to their own speciality and why a broader, less vested set of shoulders can be more appropriate for setting diagnostic criteria and treatment guidelines. Allen Frances chaired the task force that produced the fourth edition of the DSM (DSM-IV) and is Professor Emeritus at the Duke University School of Medicine where he chaired its department of Psychiatry and Behavioral Sciences. He is the author of the book Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. Timestamps: 0:00 Experts’ and Pharma’s interests in medicalization 7:30 Creating diagnostic systems and APA’s DSM publishing interests 9:54 Power balance between specialists vs. primary care 13:31 Compensating treatment and therapy before or after diagnosis? 17:00 Replacing APA as institution producing the diagnostic system 20:25 Role of DSM, symptoms and the quest for biological understanding 28:40 Becoming a public critic and witnessing the lack of progress for the severely ill Related episodes on What's Next in Mental Health? The Elephant in the Clinic: The DSM has Fallen Behind. Here is How Psychiatric Diagnosis Might Work in the Future. (with Dr. Colin DeYoung) Should We Stop Prescribing Antidepressants for Depression? (with Prof. Joanna Moncrieff) Other related materials Preventing Overdiagnosis: Winding back the harms of too much medicine (Allen Frances, talk at Dartmouth College, 2013) Psychiatry & Big Pharma: Exposed (James Davies, lecture for The Weekend University, 2019) Anatomy of an Epidemic (Robert Whitaker, book)

Virtual reality technology has been used for exposure therapy for decades but has not yet become mainstream in clinical practice. Advances in the gaming industry and recreational applications for VR have, however, made equipment increasingly affordable and available. In this episode we discuss VR exposure therapy with Dr. Andrew Sherrill who is Assistant professor and clinical psychologist at the Emory Healthcare Veterans Program at Emory University School of Medicine and specializes in VR therapy for anxiety. Dr. Sherrill guides us through what VR exposure therapy is like in practice, why it is appealing, what limitations it has and what he thinks the future will bring. Timestamps 00:00 Virtual reality exposure therapy in practice 18:00 Role of the clinician, self-help, telehealth and group therapy in VR 26:46 VR therapy results and patient preferences 31:50 Range of virtual environments in VR therapy 36:15 Fears and safety in VR exposure 42:44 Disadvantages of VR therapy 49:07 Future of VR therapy Related material NY Times: Virtual Reality Therapy Plunges Patients Back Into Trauma. Here Is Why Some Swear by It. Overcoming Clinician Technophobia: What We Learned from Our Mass Exposure to Telehealth During the COVID-19 Pandemic

Over the decades, the pharmaceutical industry and parts of the psychiatric profession lead us to believe that depression was caused by a chemical imbalance in the brain and that antidepressants helped correct it. Now a new effort is being made to say that antidepressants are effective, even if the biological mechanism is unclear. The problem is that both these narratives have been falling apart in the background for a long time. Surprisingly for many, the difference in efficacy between a placebo and antidepressant is so small that many drug trials don’t find it and most patients would be unlikely to really notice it. It’s not that change doesn't happen, it’s that it happens in the placebo groups too. And then there are the risks to take into account. In this episode, we discuss antidepressant drugs with Professor Joanna Moncrieff. She is Professor of Critical and Social Psychiatry at University College London. She is also the lead author of the impactful 2022 scientific review of the serotonin theory of depression. It is one of the 400 most shared scientific papers of all time out of the full 21 million tracked articles. This episode discusses the decades of efforts to find a biological basis for depression and issues with the diagnosis. We dive into the interpretations of the small difference between antidepressants and placebos and discuss the increasing awareness of the risks of long-term antidepressant use. Finally, we discuss the influence of the pharmaceutical industry, the professional interests within psychiatry and the research funding channels. Is the funding system protecting patient safety? How much should we curtail the indications for antidepressant prescribing? And finally, is the turning point for mass prescribing in sight? Episode timestamps: 0:00 The search for a biological basis and problems with the diagnosis 19:23 Disentangling placebo and antidepressant effects and emotional numbing 33:33 Withdrawal problems 44:05 Vested interests and high stakes 55:05 Problems with research funding 59:28 Finnish depression guidelines 1:02:50 The future of antidepressants Related materials - Molecular Psychiatry: The serotonin theory of depression: a systematic umbrella review of the evidence - The Conversation: Depression is probably not caused by a chemical imbalance in the brain – new study - Psychiatry & Big Pharma: Exposed (Dr. James Davies, videolecture) - The Emperor's New Drugs: Exploding the Antidepressant Myth (Dr. Irving Kirsch, videolecture) - Royal College of Psychiatrists: Antidepressants - NICE Guidance: Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults - Anatomy of an Epidemic (Robert Whitaker, book description)

Psychedelic-assisted psychotherapy is an area of great research interest, widespread media coverage and increasingly also financial dimensions. In this episode, we discuss psychedelic research and everything related to it with Dr. Sandeep Nayak. Dr. Nayak is assistant professor at the Johns Hopkins Center for Psychedelic and Consciousness Research where he studies treating psychiatric disorders with psilocybin-assisted therapy. He also works as a clinical psychiatrist at Addiction Treatment Services (ATS) at Johns Hopkins Bayview Medical Center. Episode timestamps: 00.00 A brief history of psychedelic research 7.40 Where the funding is coming from 10.10 Psychedelic-assisted therapy in practice 20.55 “Bad trips” and mystical experiences 27.39 Scientific results so far 38.13 Non-specific effects, relationship effects and placebo 44.43 Implementation in regular clinical practice 46.22 Risks and harms 55.45 Financial incentives and hype effects 1.01.45 Expected timeline for FDA approval Related materials: Johns Hopkins - Center for Psychedelic & Consciousness Research Multidisciplinary Association for Psychedelic Studies (MAPS) Trial of Psilocybin versus Escitalopram for Depression MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study Psychedelics, placebo effects, and set and setting: Insights from common factors theory of psychotherapy New York Magazine: Cover Story (Podcast)

Focusing on which psychotherapy is best for a specific psychiatric disorder has had limited value in providing a path to improving overall psychotherapy outcomes. Research has, however, identified multiple promising ways to boost effectiveness by personalizing treatments. Dr. John Norcross and I discuss what current research says about personalizing psychological treatments and the potential it has for improving effectiveness and decreasing treatment dropout. He also gives his take on how psychotherapy orientations are evolving, how mental health research funding should be redirected and how personalization could be part of clinical guidelines. Dr. Norcross is Distinguished Professor and chair of psychology at the University of Scranton and Clinical Professor of Psychiatry at SUNY Upstate Medical University in upstate New York. He has served as president of the Society of Psychotherapy and the Society of Clinical Psychology at the American Psychological Association and president of the International Society of Clinical Psychology and the Society for the Exploration of Psychotherapy Integration. He has also served as an APA Council Representative and as a director of the National Register of Health Service Psychologists. He has co-written or edited over 20 books including Personalizing Psychotherapy, the series Psychotherapy Relationships that Work and the APA Handbook of Clinical Psychology. Episode timestamps - 00.00 Developing pragmatism in mental health - 6.53 Relationship factors related to better outcomes - 22.05 Personalizing psychological treatments - 30.53 Training therapists to personalize - 44.20 Training therapist responsiveness vs. matching patients to therapists - 49.00 Perspectives on mental health research funding and guidelines Related materials: Psychotherapy Relationships That Work: Evidence-Based Responsiveness Psychotherapy Relationships That Work III

The field of psychotherapy has splintered into multiple theoretical orientations and over 500 different forms of therapy - each with their own theory and often with their own famous founders and competing interests. Could broadening the perspective to the cognitive neuroscience mechanisms underlying all psychological change bring some sorely needed coherence? My guest, Dr. Warren Tryon is professor emeritus of psychology at Fordham University. His book Cognitive Neuroscience and Psychotherapy: Network Principles for a Unified Theory outlines a cognitive neuroscience perspective on psychotherapy and clinical psychology. With computerized neural network models, it is becoming possible to simulate and study personality and processes of psychological change in ways that have not previously been possible in psychotherapy research. Tryon argues a network perspective is a path to explaining the basic mechanisms of change across all major psychotherapy orientations and that it lays the groundwork for a common language not only between different psychological treatments but also with pharmacology and medical professionals. The conversation gets fully going about 20-30 minutes in. Timestamps: Learning, memory and neural network models (0:00) Network understanding of exposure therapy (7:00) Pharmacological and psychological change processes (15:00) Connectionist models and solving the mind-body problem (20:25) Unifying how we view different psychotherapies (24:10) Professional identity and the problem of purple hat therapies (29:40) How to get from 500 psychotherapies to basic core principles? (32:35) Network principles (37:00) Priming in networks and in psychotherapy (44:05) Explanatory power in the science of psychology vs. the art of psychotherapy (50:50) Network-based personality models gaining traction in social psychology (56:08) Cognitive dissonance in psychotherapy (1:04:00) Can philosophical differences between psychotherapies be overcome? (1:13:01) Additional resources: - Warren Tryon’s Psychology Today blog: The Missing Link Between Psychology and Biology - Warren Tryon's Fordham University page - Warren Tryon on Elsevier SciTech Connect -blog Related articles: - Tryon, W. W. (2016). Transtheoretic transdiagnostic psychotherapy. Journal of Psychotherapy Integration, 26(3), 273–287. https://doi.org/10.1037/a0040041 - Explanation as Psychological Intervention (pdf) (Online supplement to Tryon, W. W. (2014) Cognitive Neuroscience and Psychotherapy: Network Principles for a Unified Theory. New York: Academic Press) - Read SJ, Monroe BM, Brownstein AL, Yang Y, Chopra G, Miller LC. A Neural Network Model of the Structure and Dynamics of Human Personality. Psychological Review. 2010;117:61–92. https://doi.org/10.1037/a0018131

Traditionally, psychiatric symptoms have been the primary focus in diagnostic systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). This episode questions whether there are better ways forward. This episode is a continuation of the previous episode’s conversation about reforming the diagnostic system. We continue the discussion with personality neuroscience researcher Dr. Colin DeYoung. His cybernetic theory of psychopathology combines a neuroscience understanding of personality traits, psychiatric symptoms and dysfunction in the ability to pursue our wide range of goals as human beings. We discuss ways to understand psychopathology and mental disorders. Timestamps The cybernetic theory of psychopathology (0:00) Defining psychopathology in a dimensional model (1:55) The history of the cybernetic perspective (4:00) Understanding personality traits as settings in the brain (7:00) Mental health and the ability to pursue goals (8:40) The role of dysfunction, symptoms and personality in mental illness (10:13) Should a depressed psychic be treated as a schizophrenia patient? (14:10) Cybernetic theory and case conceptualization (19:25) Etiology in mental disorders vs. disorders of the body (21:45) Intervening with psychological vs. biological treatments (30:00) Mental illness doesn’t need to be seen as a permanent trait (34:45) Links The DeYoung Personality Lab: https://deyoung.psych.umn.edu/ More podcasts and videos with Dr. Colin DeYoung: https://deyoung.psych.umn.edu/personality-sites

The DSM and ICD diagnostic systems are lagging scientific understanding of how mental health and mental illness work. This episode discusses the future of mental health diagnostics with personality neuroscience researcher Dr. Colin DeYoung. Dr. DeYoung is Associate Professor of Psychology at the University of Minnesota where he runs the DeYoung Personality Lab. He is a member of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium, a sizable group of scientists attempting to create an improved diagnostic system. The DSM “bible of psychiatry” has been seriously criticized, especially, since the development and release of its fifth edition in 2013. At this point, the world’s largest mental health research organization, The National Institute of Mental Health (NIMH), announced it would reorient its funding away from DSM-based research. As a response to shortcomings in the DSM and ICD, the HiTOP consortium was formed in 2015. It is a grassroots effort to create a data-driven diagnostic system based on statistical analysis of how different mental health symptoms occur together in practice. HiTOP has been accumulating evidence of its utility. This episode is the first part of the conversation with Dr. DeYoung. In it we discuss how the DSM-V and ICD-11 systems have fallen behind progress, how HiTOP works, and how it relates to both the DSM and ICD systems and the Research Domain Criteria framework launched by the NIMH. We also touch on the power politics involved between different medical fields and how HiTOP becoming a clinical reality could unfold. Episode timestamps: Discontent with the DSM and ICD systems (0:00) The gap between science and practice in psychiatry vs. other fields of medicine (4:40) Problems with viewing psychopathology as categorical disorders (9.00) NIMH launched RDoC as an alternative framework of studying brain mechanisms (18:35) HiTOP vs DSM and ICD vs RDoC (21:15) How helpful is defining mental disorders as brain disease? (28:05) HiTOP as a statistical model for how symptoms co-occur (32:40) Clinicians operating in practice (46:05) Power politics between different medical fields (52:20) The path forward to implementation and official recognition (1:00:33)

Dr. Bruce Wampold is Emeritus Professor of Counseling Psychology at the University of Wisconsin-Madison. He was, until his retirement, the Director of The Research Institute at Modum Bad Psychiatric Center, Vikersund, Norway. The American Psychological Association and Society for Psychotherapy Research have both granted him awards to celebrate his career and contributions to psychotherapy research. He has authored or co-authored nine books and countless book chapters and research papers and pioneered the Contextual model of Psychotherapy. The debate, whether some psychotherapies are superior to others, started decades ago. At the turn of the millenium the first edition of Dr. Bruce Wampold’s book, The Great Psychotherapy Debate raised the discussion to a new level. According to Wampold’s contextual model of psychotherapy the specific treatment is secondary to more important factors influencing outcomes e.g. the therapist relationship, healing context, explanation for distress and the therapeutic actions that are consistent with the explanation. In this episode we ask Dr. Wampold about his path to becoming a psychotherapy researcher and his views on psychotherapy research and the possibilities beyond comparing different psychotherapies. Episode timestamps: 0:1:25 From mathematics and teaching to psychotherapy research 0:4:00 The traditional way of viewing psychotherapy 0:6:30 Randomized clinical trials and their limits 0:10:50 What happens when people heal in psychotherapy? In Dr. Wampold’s view, we already know a lot about how psychotherapy works 0:16:25 Differences between therapists and how therapist characteristics like empathy affect outcomes. 0:19:10 Dismantling studies in psychotherapy - what are the results? 0:27:10 Can focusing on the most effective treatment lead to overlooking more relevant factors? How important is diagnosis in tailoring treatment? 0:37:20 How can we improve the system? Affecting therapist training. 0:48:06 Therapist flexibility and breadth of expertise relative to client needs 0:57:10 How can we help psychotherapy continue to evolve in the future?