Exploring the Evolution and Impact of CBT with Blake Thompson

In this episode of the Relational Psych Podcast, Dr. Claney delves into the transformative world of personalized Cognitive Behavioral Therapy (CBT). Join us as we explore how tailoring therapy to individual needs enhances its effectiveness and patient satisfaction. We discuss the evolution from traditional manual-based CBT to a more adaptive, patient-centric approach, examining its impact on mental health treatment. We cover the challenges, benefits, and practical applications of personalized CBT, making it a must-listen for therapists, psychology enthusiasts, and anyone interested in the future of mental health care.

Seattle Anxiety Specialists (SAS)

SAS’ psychiatric medication management program is stellar and is designed to overcome exactly the issues that have befell psychiatric medication management of late. We offer highly individualized care, with psychiatrists that maintain relatively small caseloads, who really take the time to get to know their patients (e.g., they only do two follow up appointments per hour rather than the 4 (or even 6!) appointments per hour that is sadly becoming more and more the norm. 

SAS is launching a new group therapy program in the next couple of weeks that aims to provide a version of CBT that's grounded in its philosophical roots. "First wave" folks like Skinner were reading the Vienna Circle (including Wittgenstein), Beck and Ellis were reading ancient Greek and Roman philosophers like Epictetus when they developed the "2nd wave", Hayes and Linehan were reading and Buddhist philosophy as they developed the "third wave" (ACT, DBT, etc.). This group therapy program that I'm running is going to draw on these evidence based practices and do so in a way that really honors their philosophical foundations (which I'm especially well positioned to do because I've also got a graduate degree in philosophy). 

Association for Behavioral and Cognitive Therapies

Book Recs: Lots of newly minted providers are trained in CBT in their graduate programs, but the most important thing that these new providers need to do is to throw away their worksheets and adopt a process-based, case-conceptualization driven approach to the care they offer, and they can't go wrong by picking up one of these books to help them guide that transition:

• The Case Formulation Approach to Cognitive-Behavior Therapy by Jacqueline B. Persons
• Process Based CBT: The Science and Core Clinical Competencies of Cognitive Behavioral Therapy by Stefan G. Hofmann and Steven C. Hayes
• Learning Process-Based Therapy: A Skills Training Manual for Targeting the Core Processes of Psychological Change in Clinical Practice by Stefan G. Hofmann, Steven C. Hayes, and David N. Lorscheid
• Socratic Questioning for Therapists and Counselors: Learn How to Think and Intervene Like a Cognitive Behavior Therapist by Scott H. Waltman, R. Trent Codd, III, Lynn M. McFarr, and Bret A. Moore
• Schema Therapy: A Practitioner's Guide byJeffrey E. Young, Janet S. Klosko, and Marjorie E. Weishaar

Blake’s Socials: 

- Instagram
- Facebook
- LinkedIn

© Relational Psych 2023

W: www.relationalpsych.group
E: hello@relationalpsych.group
P: (206) 589-1018 

Transcript

Exploring the Evolution and Impact of CBT with Blake Thompson
===

[00:00:00] 

Carly Claney: If you want to learn about psychological growth without getting lost in complicated language, you're in the right place. This is the relational psych podcast. I'm your host, Dr. Carly Claney. Licensed psychologist and the founder and CEO of relational psych. On this show, we learn about the processes and theories behind personal growth. Please keep in mind that this podcast isn't a substitute for therapeutic advice, but we're here to point you in the right direction.



Carly Claney: Well, today I have Blake Thompson here speaking with me. Blake is a licensed mental health counselor and the founder and executive director of Seattle Anxiety Specialists.

It's a group psychiatry, psychology, and psychotherapy practice in downtown Seattle that was recently recognized as one of the best mental health [00:01:00] practices in the Pacific Northwest, according to the Seattle Times Reader Choice Awards. So, congratulations and thank you so much for being here. 

Blake Thompson: Thanks. Yeah, I'm glad to be here.

Carly Claney: Well, today the topic we're talking about is cognitive behavioral therapy specifically its effectiveness and how it relates to patient satisfaction and psychiatric medication management. So a lot to talk about there. And as we get started, I'd just love to hear a little bit of like, why are we talking about this?

Blake Thompson: Yeah. Yeah. Well, you know, we're talking about this because there's this is growing awareness that we need access to mental health services. And I think there's also sort of following from that. Now, there's also this growing awareness that there's a huge disparity in the quality of mental health services.

And so that's what I want to address today is that disparity in the quality of mental health services. Like what explains that disparity? Like why are some patients really satisfied with the mental health services they get? And other patients are really dissatisfied with the mental health services they get.[00:02:00] 

I can't, I'm not going to answer that whole question today. That's like a doctoral dissertation but we're gonna talk about CBT specifically and talk about psychiatric medication management specifically because at least part of the story about why some patients are really dissatisfied with the services they get have to do with those kinds of mental health services specifically and changes that have happened in CBT delivery and in psychiatric medication management delivery over the last few decades. 

Carly Claney: Yeah, this feels really important because I think you're bringing up a lot of things, both the historical timeline of how things have developed, which I think is always so vital to contextualize ourselves and to where are we now in history and what came before and where are we going.

But you're also bringing up a lot of interesting ideas I want to get deeper into. some of the words that stuck out to me are satisfaction and quality which are things immediately. I'm just thinking how subjective those can be and maybe how hard to measure they [00:03:00] are. But I'm curious if we could start at the basics.

Can you tell me what is CBD? It's a CBT. What are we talking about here? 

Blake Thompson: Yeah. Yeah. So it's not cannabis, right? That's CBD. Yeah, totally. Yeah. So cognitive behavioral therapy is, is CBT. It's actually a pretty broad term the way that it gets used by the association for behavioral cognitive therapies.

It includes a lot of different types of psychotherapy. It includes prolonged exposure for PTSD, cognitive processing therapy. It includes acceptance and commitment therapy. It includes dialectical behavior therapy. There's a lot of things that fit within this umbrella. But loosely, there are these three theories of psychopathology that are considered by the community like, the folks at the Association for Behavioral and Cognitive Therapy they consider these to be like the gold standard models for conceptualizing psychopathology [00:04:00] and all of these therapies are based on these theoretical models and there's a lot of like really rigorous empirical testing of the models and a lot of really specific interventions.

And we're going to talk about this in a second. There's a lot of approaches to treatment that have been manualized. So one, one of the things that is going to really distinguish CBT from other kinds of therapy is manualization, right? There's a lot of manualization in CBT, there's not a lot of manualization and other therapies, right?

What distinguishes CBT from other therapies has a lot to do with the particular approach to research, this very quantitative, very behaviorally oriented kind of research that gets done and the, the delivery mechanism, right? So CBT has evolved to look a particular way.

But if you wind the clock back and we ask what is CBT? I think the easiest thing to say is, well, it's had these three waves. There was the first wave, which was behaviorism, the second wave, which gets termed like the cognitive revolution, [00:05:00] and then the third wave, which involved the integration of Buddhist insights into psychotherapy in ACT and DBT and now there's this sort of like loose alliance between these ways that exists . Again, it's this broad umbrella of evidence based approaches to psychotherapy. 

Carly Claney: Well, I'm hearing it's both like this, this big category.

So when we're talking about CBT, it's a umbrella for a lot of different things that fit into it. And it's also, I don't know if it's right to say it's a movement, but it's been this development in psychotherapy over years with these different waves. That has grown. It's evolved. It's been different things at different times.

And I think it's important to know that with our practice at Relational Psych, most of us have had training in CBT or integrated in different ways, but at our core, we approach it from a psychodynamic, psychoanalytic perspective. And so could you contextualize CBT historically? When did it come about in terms of the broader [00:06:00] psychoanalytic history? 

Blake Thompson: Yeah, that's a great question. So, psychoanalysis generally existed separate from university psychology departments. There were these psychoanalytic training institutes still are that people get their psychodynamic and psychoanalytic training from once they graduate from their doctoral programs.

A lot of independent professional schools of psychology, independent from universities, institutionally there was sort of this divergence. And behaviorism, which is the first wave of CBT grew up within the universities. So within psychology departments you know, Skinner at Harvard and then also in Europe they're folks like Pavlov, you know, we know a lot of jokes about Pavlov and their progeny like, Vilhelm Wundt and you know, Helmholtz and all these people who in different ways sort of, developed positivistic neocontine ways of conceptualizing what psychology was going to be empirically and yeah, they, they started to develop therapies[00:07:00] based on their experimental work.

Carly Claney: It sounds like while psychoanalytic training was developed in these more, I don't know, individual private institutions, you're saying that behavioralism really came from the university.

It came from educated systems. 

Blake Thompson: Yeah. So, obviously the analytics centers were full of MDs, right? Those were the only people that were allowed to practice psychotherapy, you know, a hundred years ago. Psychologists could do testing, but they weren't even allowed to do psychotherapy. In Illinois you know, 60 years ago, you couldn't practice psychotherapy as a psychologist, I don't think. Wow. Yeah, it's, you know, kind of bananas the history too and how that all syncs up with this. But yeah, psychologists kind of started CBT and it's very much in step with psychological testing that they developed for the U. S. government, for the French government. They developed IQ testing, they developed aptitude testing, they developed all this kind of interesting stuff. And they were focused on not just human behavior, but animal behavior, and really trying to figure out, like, what were the laws of the human animal, right?

[00:08:00] And how do we boil it down. Like Skinner would say, like, could I take any infant put them through the right series of experiences and predict who they were going to become based on these inputs and outputs . We now know, things like genetics, play an important role in mediating changes.

Right? But back in the day there was this strong curiosity about like, " how do we not forget about introspection, forget about qualitative stuff. Forget about talking to the person", right? There was this curiosity about " can we become like super empirical in a really narrow sense?"

Like, can we bring a fine glass to human behavior and really create a predictive science? And they did learn a lot. They created exposure therapy and behavioral activation. Like that's what fell out of the first wave. Like they, they really did figure out that if somebody's depressed, having him go off into the world and like do stuff, you know, like drag them out of bed, get them in the shower, get them a job, [00:09:00] get them out of the house. That helps. It's really, it's, there's a reason behavioral activation is still like one of the gold standard treatments for depression. And they also figured out that if people are really anxious, having them face their fears. Right? Like they have a phobia of snakes, like putting them in a room with a snake for four hours, like the nightmares go away after that .

It's, it really is incredible. And so they had some wins and I think in general, we make jokes about them for a reason, right? They missed a lot too. Like we shouldn't look to the folks who started CBT for all the answers, but they, they got us pretty far.

They got us exposure therapy and behavioral activation and that was huge. And then what we think of mostly today as CBT is Albert Ellis and Aaron Beck's contributions that came in the last half of the 20th century. And what Beck was a psychoanalyst. A lot of people don't know this about him.

He was an MD. He went through psychoanalytic training practices, psychoanalyst.[00:10:00] But he was also really interested in this emerging field of clinical psychology and in behaviorism. And he was reading everything. He was like, voracious. He read a ton of philosophy. He was reading a lot of ancient Greek and Roman philosophers with Albert Ellis, who was also really interested in that and eventually came to develop this approach to therapy, which kind of blended behaviorism with the psychoanalytic work he was doing. He was also really influenced by Carl Rogers, who had Developed his own, kind of neo Adlerian approach to therapy, which was really cool.

Carly Claney: I'm curious when you bring up Beck And being influenced by Carl Rogers, which is very person centered and more supportive therapy, maybe. What did Beck do with behaviorism?

Like, how did it evolve then from that into more of this mix that values, cognition, values emotion, values different 

Blake Thompson: things. Yeah, I mean, Beck , his actual clinical practice was like this grab bag of things. You know, he pulled from his analytic [00:11:00] training. He pulled from what he was reading Carl Rogers.

He pulled from the philosophy he was reading. He pulled from behaviorism. He was having his patients do exposures to overcome their fears and was encouraging them to get out of the house if they were depressed. 

Humanism had this model of psychopathology, which is humans are like plants, you know, if you give them food and water and sunshine, they're going to do great. 

And Beck agreed. He thought " that's a really interesting perspective". He thought the behaviors had a really interesting perspective. And he thought the way that we interpret our reality, the way that we interpret ourselves, the way we interpret our life, the stories we tell ourselves about ourselves, what he called the cognitive layer. Most of the cognitive stuff that Beck cared about was unconscious. Right. Which makes sense for somebody with psychoanalytic training, right? Yeah. And most of the cognitive stuff was how, how do we interpret our living reality?

You know, it's, and he pulls really heavily him and Ellis pull from Epictetus here. The quote that they loved from Epictetus was [00:12:00] "man is not disturbed by things in themselves, but by the view they take of things". 

Carly Claney: Ah, the interpretation. 

Blake Thompson: Yeah, it's the interpretation. And so when they use the term cognitive, that's really what they're getting at is the way that we make sense of things.

The significance that we attach to things. And from 

Carly Claney: that, I could also imagine like a lot of routes that we take, the patterns, the repetition, the, the default of this happens. And I tend to interpret it this way again and again and again, even if let's say the experience changes slightly. It sounds like there's a a lot of space for, for that more unconscious process and the way those thoughts are interpreted .

Blake Thompson: Absolutely. Yeah. A lot of good cognitive therapy involves what's called the downward arrow technique where you ask the client, what are their thoughts about something, and they say, "well, such and such would be really scary".

And then you ask, well, yeah, why would that be so scary? What would be so [00:13:00] scary about it? Well, because of X, Y, and Z. Why would that be significant? Like, why does that matter to you? And you're, you're trying to get at layers of their interpretation that they aren't aware of, but that are there.

You're trying to bring the unconscious thought to the surface so that you can process it and deal with it. It sounds pretty psychoanalytic. 

Carly Claney: I was saying, you're sounding a little analytic there. 

Blake Thompson: Yeah, totally. I think there's a strawman version of Aaron Beck that is fairly maligned, obviously, like if all we're talking about are conscious thoughts, yeah, that's a pretty poor Model for doing psychotherapy.

I think there's a version of Aaron Beck that gets taught a lot that is a really dumbed down version of it. And I don't think that's a really useful model. I think we've got to like, actually flesh these ideas out a lot more for them to have usefulness and for them to not end up [00:14:00] oversimplifying the work in a way that's really problematic.

Carly Claney: Yeah, I think one of my critiques of that when I learned about it and even now it comes back to the manualization of it because I feel like there is a forcing then of dumbing it down or simplifying and oversimplifying it when we can say if it's in this neat little package, this neat little book that we can just follow almost mindlessly.

And I don't even say that judgmentally to say it mindlessly. I think there is a need in research to make it mindless, meaning making it yeah. Observable, making it operational, like, so that we can really make sure that when we test something, we know what we're testing and we know that we're going to get the same answer.

Blake Thompson: Yes! Yes! Right? Which is one of the two reasons why manualization has happened. And I think there's been this then misperception that like manualization is the way to go like the best version of cbt is to stick to the manual. Yeah, we manualized because it allowed us to be [00:15:00] really precise in doing quantitative empirical research that we wanted to do. That was really helpful.

Like we could make sure we were testing this particular variable and not any other variables. Right, which is great. Like, we wanted to know, like, does spending five versus 10 minutes reviewing the previous session at the beginning of this session, impact therapeutic outcome.

It's like the psychoanalysts were bored to death of that question. They were like, we're not researching that. The CBT people are like really anal about these things and they do like 80 studies on that one question to just make sure. And you know, like that's there it's, you know, university departments, right?

That's their whole shtick. They just like. I 

Carly Claney: mean, again, it's, it's in those educational institutes. 

Blake Thompson: Yeah, that's where it grew out of, right. And it grew out of people who were really anal about things in that particular kind of way. And so of course, manualization was going to happen, right? Like that's, that makes sense.

And the other reason that manualization happened was [00:16:00] so that somebody with an associate's degree, like a two year college degree in a church basement in Leeds in the UK could run a dbt group somewhat effectively. Mm-hmm. Right. The NHS was actually a huge push for manualization. They put a ton of money into taking the efforts of these CBT researchers to take their manualized therapies and make them usable by folks who didn't have clinical training to expand the access of psychotherapy.

Wow. To folks that wouldn't otherwise have access. And this is part of the reason why there's a disparity in quality, like obviously somebody who doesn't have any clinical training isn't going to be as effective as somebody who's like you has a doctoral degree in clinical psychology. Like we wouldn't expect similar effectiveness, but the reason why manualization is so widespread in clinical practice is in large part owing to organizations like the NHS that really [00:17:00] did invest heavily in making therapy as widely accessible as possible. 

Carly Claney: That seems so tricky because I can see the pros and the cons of that, the double edged sword of increasing access and then also increasing the research capability where we can find out, like, what does what is effective and what does work and all of that. But then, like you're saying it, it really does limit than in some ways the quality or, I almost think that then we start to, we don't realize this, but we start to compare apples and oranges because we might say all CBT is the same when it's following the manual when you're saying that more qualified or experienced clinicians probably aren't following the manual.

They're probably bringing in a lot more of their own experience and education in a way that the manual doesn't 

Blake Thompson: prescribe. Yeah. I mean, they're the more experienced CBT clinicians do CBT in a way that looks more like what Aaron Beck was doing when he did CBT. They're doing what works and they're[00:18:00] definitely pulling from all this CBT research. The CBT research is really valuable. It gives us really good insight about psychopathology, really good insight about it. Like it's, the theories are really well empirically supported, but the practice of strictly following a therapy manual, that's actually not as well empirically supported as you might think, based on how well the theories that those manuals are based on are supported.

So that's a discrepancy that we don't distinguish enough. A better version of CBT is the provider really understands really well the theories of psychopathology and is able to assess because they've had a lot of good clinical training, assess the patient in front of them really well and apply those models of psychopathology to the individual case in front of them and come up with an individualized treatment plan that maybe pulls [00:19:00] some different interventions from some different manualized approaches and treats those as like jumping off points. Like in this approach to treating OCD that was developed by this person, like they came up with this intervention.

And I think that something like that, that maybe I'm going to modify in this way would be appropriate for this client in this context, that is really good cBT. Just following the manual often, There's really low patient satisfaction, there's really high treatment dropout rates for that approach and I think that should be obvious.

Carly Claney: Well, I'm curious about that because it, I totally agree with you. I think it's obvious to you. I don't want that kind of therapy for myself where it's just, you know, manualized. And yet I think it comes back to this reflection about effectiveness. When I think what we're saying now is the research is saying this is effective, this, this, Closed circle of this is what CBT is.

This is effective. But again, I think what you and I are saying is what's more effective is not doing that. [00:20:00] It's not following the manual. It's expanding it and bring in other things that the research probably didn't actually do. Is that true? 

Blake Thompson: Yeah. I think the best of the CBT researchers, I think acknowledge that it takes a lot of different models of psychopathology to be effective and they have a pretty expansive view of the work that they do right there. They think like yeah I want to understand the sources of my patients suffering and then craft an individualized approach that meets those needs and when it's a phobia or OCD, they're going to pull from behaviorism when it's a generalized anxiety disorder, they're going to pull from Becky and CBT. When it's a personality disorder, they're probably going to pull from psychodynamic theory, right? They have an expansive idea of what's useful here. You know, like Marshall Linehan, who developed dbt, which is part of this broad cbt umbrella, she was Otto Kernberg's graduate student. Like these connections are like way more nuanced than we think they [00:21:00] are, right? Then then gets presented to us often. Even as clinicians, but certainly to people outside of clinical practice who would have no idea that there's so much in a relation between these approaches to work.

And I think it's worth honoring the fact that manualization did expand access to care and it has really helped us understand things like in, in terms of working with OCD, for example, it's taken decades of doing empirical research on OCD, but it's pretty clear now that we've developed multiple models for working with OCD and we've figured out what's effective, and we've also done a lot of causal mediation research. So we know now that once compulsions are able to drop off, once we can find a way to curb those that then intrusive thoughts will follow, they will drop off. We didn't know that at first . So all of this like really anal research work that talking about and the manualization that allowed us to get there, that was really valuable.

And the manualized versions of those that again, some non clinician could help someone out with [00:22:00] in a setting where someone in rural Kazakhstan where there are no psychologists. There are no health counselors. There's no psychiatrists. Yeah, like, can you download a PDF from the internet and like follow the thing and like, maybe it will help you.

That would be wonderful, right? So we really, I want to honor the fact that manualization is this really wonderful thing and really strongly, I think, push back on this. It's good. This idea that somehow taken hold, like doing the manualized approach, by the letter is the gold standard. 'cause it's not like that's a misconception that we have to make sure we clear up.

Carly Claney: Yeah. Yeah. Do you have any idea of where the misconception comes from? Like, is it more from clinicians or is it from the media or clients? Like why are we thinking that that's the 

Blake Thompson: case? Yeah. That's a really good question. I think there are a lot of academics who have never practiced in clinical practice who have convinced themselves of [00:23:00] this.

So that their contribute to this from the CBT end. So that's definitely a wing within the CBT world. You'll hear folks say stuff like that. And I think that that is wrong. And then I think there are a lot of folks outside of CBT who, what they know of CBT is the manualized stuff.

Like that's what they see. And they're like, I don't want to do that. And I don't want that for me. And they think that that's what it is. Like, that's all it is. And then that's the majority of everybody, right? There's like not, you know, like that's a lot. It's like, 70 percent of the people who are in the know think it's supposed to be something that it is only provisionally . 

Carly Claney: Yeah. I think we hear that a lot from clients who come to us and say, I don't just want homework. I don't just want to go through worksheets.

Like I'm so much more than that or like I need so much more nuance than that. But then on the flip side, I can even imagine. More in my specialty, there's so many misconceptions about what psychoanalytic work is, and [00:24:00] it's so hard to break through what the cultural conversation is around it.

Because like you're saying, the majority are not aware, like the minority of 

Blake Thompson: people. They think you're going to have them lay on the couch and sit behind them and not talk, right? And it's all going to be about psychosexual stuff. Yeah.

Carly Claney: Yeah. So I'm coming back to this idea of effectiveness and you brought up the idea, I think earlier on about medication management and patient satisfaction . What are your thoughts on how those two connect?

Blake Thompson: So there's a lot of meta analytic research that seems to show that over the last few decades, the last four three or four decades, the effectiveness of CBT has been decreasing on average.

And that's wild. Cause in the eighties, CBT was super effective. It really like made a name for itself because it stood out. Like when in head to head clinical trials, it did really well. That's why, you know, it got so much funding. It was [00:25:00] like and now it's really slipping. And why is that? And I think a lot of the reason for that is that it's been dumbed down. It's been watered down. It's been manualized, right? And It's lost a lot of the elements that that made it effective a lot of these like common factors. You know, it's it's lost the influence of psychodynamic therapy. It's lost the influence of humanism It's lost, you know in so many clinical settings not in I think the high octane ones where you know Ideally people would be getting their care.

But there's a reason why it's lost that effectiveness and I think acknowledging that is really important. Psychiatric medication management has seen a similar decline in terms of patient satisfaction. And in terms of outcomes where decades ago, patients were generally pretty satisfied with their relationship they had with their prescribers.

And these days when you poll people, they're very dissatisfied with their relationship. Part of this is how corporate interests have gotten involved in healthcare. And really like squeezed everybody, you know, like systems and [00:26:00] bought up all of these private practices insurance companies, you know, the transition to manage care and then really trying to get prescribers to do as many appointments in a day as possible, right? Not increasing reimbursement rates for decades for network providers. There's a lot of elements here, that coalesce into prescribers no longer spending half an hour in a follow up appointment.

No longer really getting to know their patients. And now, places like Kaiser, I've I've heard of having no cap on their caseload, right? There's no, there's no limit. You're at 500 patients. Like, like we're just going to keep adding, we just keep adding and people are just going to keep scheduling and you got to do six an hour and that includes notes.

How do you do six appointments an hour? You like, you got to take notes in session while you're talking with the patient. You can't go to the bathroom. 

Carly Claney: Yeah, it starts to limit in [00:27:00] so many ways. I mean, the big one being time, but then I'm just thinking about, like, capacity of doing anything of knowing the patient of remembering the patient of all the things that then changes the environment or the context of then how the work is being done.

It just, it takes away opportunity of any kind of, in my opinion, any kind of like good work to really happen then. 

Blake Thompson: Absolutely. And we like to think that, you know, esotelopram is esotelopram is esotelopram. But part of what is important in people's mental health journey is the relational piece, right? That is genuinely Healing for people is genuinely helpful to feel seen, to feel heard to feel supported in their journey.

They, they want to sit down with their doctor and not feel rushed and they want to feel that they can trust their doctor, that they can divulge stuff to them about side effects. If they're, like, rushed through an appointment, they might not bring up that they have side effects to the medication they don't [00:28:00] like.

A lot of these issues start to get swept under the rug in the name of efficiency. And it's similar to manualization and CBT, right? If we have a limited number of psychiatrists, and now they're all seeing twice as many patients, well, that expands access, which is good.

But the quality of care declines in response to that. And that's a really important thing to take note of. I don't know how to square that circle either, right? It's like, do we, you know, only allow psychiatrists to do 30 minute followups? Well, that would like drastically increase the shortage of qualified psychiatric prescribers.

So that's not, that's not good. So it's not easy to say what to do about this, but it, we should be acknowledging that when people have a seven minute appointment with their psychiatrist instead of a 25 minute appointment with their psychiatrist, they have worse clinical outcomes.

Even if they're on the same, even if it's the same drug, they're, they both get Lexapro, but a psychiatrist that can spend more [00:29:00] time dialing in the right dose, building trust so that the patient, understands that it's okay for them to take the drugs, to improve med compliance, there's, there's so many variables too here, right? And we miss all of that relational stuff.

The relational stuff is important because it can improve The precision of the psychopharmacology involved, but also because that human relational stuff is also an important antidote to what ails us. 

Carly Claney: Yeah. I'm thinking of those researchers who, who cared so much about the five minutes versus the 10 minutes of reviewing.

I wish they could know this and think about the the amount of time needed in a session, but I do want to go back a little. I, I, I feel like a lot of people even listening or us now, we can assume a lot of what might go into what we mean by effectiveness. But I wonder if we can outline a little bit of what that means.

Like, what are we saying when we talk about this is less effective now than 

Blake Thompson: it used to be? Almost always what we [00:30:00] mean when we talk about effectiveness and mental health research is this sort of binary of what percentage of the patients in the study achieved remission by the cutoff point, which is usually somewhere between, like, 12 and 16 weeks for the study 

Carly Claney: that we remission of the diagnosis or reduction of 

Blake Thompson: symptoms.

Right. So they're, they're not going to have no symptoms, but they're no longer going to like fully satisfy the diagnostic criteria for whatever the study was on. Like, if it was on PTSD, you know, they met the diagnostic criteria when they started the study. And now at the end of the study, they no longer qualify for the diagnosis, even though they still have anxiety or whatever, but it's not, it's some subdiagnostic now after 16 weeks.

There's other ways to measure effectiveness, but that's the most usually when when a study is done and there's a claim about effectiveness. Usually, that's the model. 

Carly Claney: Would you say that's different than patient satisfaction? Is that a different variable that's [00:31:00] measured differently? 

Blake Thompson: Yeah. So patient satisfaction relies on the subjective report of the person.

Like, yeah, how satisfied are you? And usually patient satisfaction information is getting pulled from like health systems, right? It's usually not like in the context of like a clinical study on a particular intervention. It's usually like, bigger surveys of a population.

And those can be tricky . You know, survey data is harder to interpret than experimental data for sure. 

Carly Claney: Yeah, yeah.

Well, we're coming to the end, but we still have time. What else have we not talked about? Is there anything else that we've missed here? 

Blake Thompson: That's a good question. Well, I do want to say that, for anybody listening, for anybody reading the interview if you're interested in learning more about the kind of CBT that I've been talking about today I've got some book recommendations, and I think, Carly, you're going to maybe put those links in the chat, so you can check those out.

I'll put links, 

Carly Claney: [00:32:00] but is there anything you want to call out about CBT? Those books specifically, why they're may be different than other manuals or 

Blake Thompson: books? Yeah, I think we're starting little by little to experience a kind of CBT renaissance and like pull away from this view that manualization is this gold standard.

And so there's more and more of these kind of books getting written, right? I gave you I think five of them that I like that are pretty recent. Those are books that are really accessible. And I think they, they model CBT in a way that's different than a treatment manual that you might be used to. So if you're, if you're coming out of grad school, and that's your world. You know, you're about to head out into the therapy land with your worksheets, pick up one of these books and understand that the best version of CBT is more than probably what you've been taught.

Right. It involves bringing your full human and intellectual self, your creative self to the table in a way that you might not realize [00:33:00] was even possible. So, I invite you into that. And, and for folks who are therapists have been turned off by CBT, the thing I want to invite you guys to do is forget about the manuals, right?

We want to be in conversation with y'all, right? we think we're in possession of some really good, rigorously tested Theories of psychopathology that aren't all encompassing. They don't explain like every disorder, every instance of human suffering. But we think we've done over the last many decades, some really rigorous research.

And we think we've figured out some really good theory. But the stuff that turns people off about CBT, the, the manualization. Yeah. Like let's dispense with that. The stuff we want to share with y'all are the theories, the theories of psychopathology, that's the diamond in the rough here.

And if you can take anything away from CBT, it's those models of psychopathology and those are really useful, [00:34:00] but they explain why exposure therapy is effective. They don't tell you to do exposure therapy in a particular way necessarily, but understanding those theories of psychopathology, I think, can enrich the clinical work of all clinicians in the same way that for providers who are, who gravitate much more towards CBT like I do, I've been deeply enriched by reading Kohut.

By reading Carl Rogers, by reading about feminist therapy, you know, I, I'm bringing in a whole myriad of different ideas and perspectives yeah, so I just want people to, to know that, we think the theories are really good. And so we, we do want to share those. And we think folks across the clinical spectrum will benefit from understanding them. But we do think like that's the thing we have to offer.

Carly Claney: I really appreciate that point because I think there I've had so many critiques of CBT over the years and and I think a big frustration or disappointment I've had with how big it's gotten and how widespread has gotten is [00:35:00] what has been lost, which I think you did a really good job of articulating and also I think how it paved the way for managed care and insurance companies and research and all of that to kind of get so big and lose so much of the, the I want to say magic of therapy, but it's not magic.

But anyway, I think I have so many critiques of that. And I think, again, I just feel disappointed sometimes when it just feels so one dimensional. And yet I think your emphasis there on, on it's about the theories is like exactly what I would think about just any theory, like psychoanalytic theory, theory of the world, theory of humanity, existential theory.

Like all we're doing is, is coming up with these theories and applying them in different ways and wanting to. Get to know people in that relationship. And I think there's just so much good there. And I appreciate your, your feedback in that way, because I think it would be such a loss if, if any of us are trying to be so restrictive of, I'm trying to keep that theory out, or I'm not interested in learning from that group of people or that group of [00:36:00] researchers or whatever it might be I think that's, that's more damaging than anything.

A final question for anyone who's listening who's a client who might be curious about CBT, maybe is skeptical of CBT Is there any, like, questions or thoughts that they should either bring to themselves or to the potential therapist in light of 

Blake Thompson: this conversation?

Yeah, you know, if you want some good language to use, I would ask any potential CBT therapist that I was going to send my kids to, or my other family members, you know, I, I would want to know, like, you know, do you have. Do you take a more case conceptualization process based driven approach to CBT, or do you use a more manualized approach?

And if they don't understand the question or if they answer more manualized, I would not hire that person probably. So I, I think that's a pretty clear way to like, get at the distinction that I'm trying to drive home here. If they understand the ask and they're emphatically in the first category.

That's a [00:37:00] really good sign. 

Carly Claney: Yeah, that's I love that. I just want to repeat that that asking if they have a more case conceptualization approach or process based approach and then your answer will be if they even know what you're talking about and if they're able to really delve into that and maybe even explain to you more.

So what that would mean to them. 

Blake Thompson: Yeah. And there are contexts in which it makes sense for someone to do the more manualized stuff. Sometimes insurance companies dictate that they do that.

And so in order to use your insurance benefits, which maybe you need to do in order to access care, you have to go see the person that does the more manual is like, that's okay. Like, I don't think that that's going to be like bad care. You know, we're, we're sort of comparing like what's what's Good versus great care.

I don't want to turn anybody off of like, yeah, going and seeing the manualized person if that's what needs to happen. But at the same time if you have access to somebody who can do a more case conceptualization driven process based you know, [00:38:00] individualized approach to the work probably you're going to like that better.

Your chances of terminating treatment before you get better are going to be lower. Those are the two variables that are going to be most heavily impacted here. And you're not going to have some 3rd party, some corporate interests inserting themselves into your care and dictating how things get done.

Again, like, I don't mean to say like the manualized stuff doesn't work. Clearly the manualized stuff works, they do manualized therapy, the VA, and they're really fucking good at it.

You know, they can get people reliably into remission from PTSD in 12 weeks, right? They're like, they're good. They're really, really good. And the FOA who developed prolonged exposure therapy for PTSD, who is like very well deserved. Inclusion on the time magazine, you know, a hundred most influential people of the year.

Like she, you know, invented evidence based PTSD care, right? Like amazing. Right. Love it. [00:39:00] And not everybody is going to want like the intensity and the rigidity of that kind of treatment. Like there's a reason that it's got such a high dropout rate, right. When it's done in context outside of the VA. So just being mindful of those things and making sure you're really informed about what you're signing up for.

Carly Claney: Yeah, and knowing what you think would work best for you too. Yeah. Yeah. Well, thank you so much. If anyone's listening to this and thinks you're really cool or has really enjoyed what you have to say is there anything that you offer or your practice offers that could get more access to this kind of work?

Blake Thompson: Yeah, the kind of CBT that I'm describing is the kind that we offer at our practice. We're in the process of developing some group therapy offerings for CBT which I'm really excited about. And I touched on this a little bit, the folks who developed CBT loved philosophy.

They were like philosophy nuts, right? Like the the first wave people were reading the Logical Positivists the, like, of the Vienna [00:40:00] Circle, Ludwig Wittgenstein, like all these really important 20th century philosophers Beck and Ellis, who developed second wave CBT were really into ancient Greek and Roman philosophy like Stoicism, you know, they were reading Plato and Aristotle, they were like heavily influenced by Epictetus and then the third wave folks like Linehan and Hayes, who developed stuff like DBT and ACT they, they were heavily influenced by Buddhism and Buddhist philosophy If you read any of Hayes, it's like, it's like dripping from the text, you know, like what, what's the source of human suffering is tells us that it's, it's language.

It's like, he doesn't mean negative self talk. He means like, We are creatures that use language, and that's why we suffer so much. Like, you know what I'm saying? This is the concept of language. Yeah, like, So the people who developed these therapies were really deep thinkers, and they have, like, a lot of [00:41:00] Cool intellectual resources to share with us and I, so I'm, I'm, I'm in the process of developing a group therapy program that it hopes to honor that.

So I'm, you know, I went to graduate school for psychology and then I also went to grad school for philosophy. I have a Graduate degrees in both disciplines. And so I'm hoping to bring my previous experience philosophy to bear to kind of like flesh that out and make that part of CBT more accessible to folks in a group format.

Carly Claney: That seems so cool. And especially I know of like in this area in Seattle, I can just imagine how many people would love that love that integration of the philosophy and be able to blend the two. 

Blake Thompson: Yeah, I'm super excited about it. And then also, you know, for folks who have had bad experiences with medication management.

Our psychiatric medication management Seattle anxiety really leans heavily in the other direction. So we really limit the number of patients that our psychiatrists [00:42:00] and that gives folks access to their psychiatrist. They don't have to wait months for a follow up appointment that's going to last seven minutes.

Our psychiatrists have. Limited caseload. So like if if something's going sideways with your meds can usually squeeze you in this week Like we'll and we'll see if for 30 minutes, you know, where we provide a lot of access so that we can make sure that quality of care is there and that relational component is present.

Carly Claney: That's incredible. That's really cool to know. Awesome. Well, all of the details of this, I'll include in the show notes and then links to all of your things, Instagram, Facebook, whatever else, anything else? 

Blake Thompson: I think that's it, carly. Thank you so much for having me on the 

Carly Claney: show. Yeah. Thank you so much. It's a great conversation.

And I just, I learned so much. So I really appreciate you sharing. 

Blake Thompson: Great. Thank you so much. Have a great day. I'll talk to you again in the future. 

Carly Claney: [00:43:00] Relational Psych is a mental health group practice providing depth oriented psychotherapy and psychological testing in person in Seattle and online in Washington State.

If you're interested in mental health care for yourself or a family member, please reach out. Our website is relationalpsych. group.