SIO301: Evidence Based Mental Healthcare, with Dr. Caleb Lack

Transcript

This transcript was generated automatically and may contain errors — the audio is the record.

0:00:11 Thomas: Hello and welcome to Serious Inquiries Only. This is episode 301. I'm Thomas and I'm joined as always by Dr. Lindsey Osterman and we have a guest. So, Lindsey, do you want to introduce our guest today?

0:00:24 Lindsey: All right. So, yeah, so our guest today is my current friend and former colleague, Dr. Caleb Lack, who is a full professor of clinical psychology at the University of Central Oklahoma. Thanks so much for talking with us today, Caleb. I'm excited.

0:00:36 Caleb: Yeah, I'm happy to be here. Thanks for having me on.

0:00:40 Thomas: Awesome because I'm a basket case. So I think this will be a great combination, ought to work out perfectly.

0:00:47 Caleb: Well, I knew Lindsay was, so I figured if she was working with someone, it'd be pretty similar.

0:00:53 Thomas: What

0:00:54 Lindsey: That's so sweet, Caleb! So, do you want to start out by telling us just a little bit about your training and your background?

0:01:02 Caleb: Sure. So, you know, like you said, Lindsay, I am a clinical psychologist. I started graduate school about 20 years ago this fall, actually. So I've been in the field for a little while. And during graduate school, my emphasis in terms of both research and clinical work moved more and more towards severe anxiety-based issues and obsessive-compulsive and related issues. So I do a lot of work with kind of what we call intractable obsessive compulsive disorder, tics and Tourette's, social anxiety, panic attacks, and then also fun assorted things that are related, like what they used to call conversion disorder, but now we call functional neurological disorder. So that's kind of where a lot of my clinical work is so

0:01:53 Thomas: Is that? I don't know, I don't think I know either of those terms. It

0:01:56 Caleb: So conversion disorder is where you are expressing addressing physical or psychological distress in a physiological way. So I've treated folks with that who presented initially as having things like epilepsy or severe motor tics, trouble with sight, like I can't see part of the times, things like that.

0:02:22 Lindsey: It's a psychological cause.

0:02:24 Caleb: Yeah. Yeah. So we rule out all potential physiological causes first. And then they usually, the neurologists say, well, why don't you go see this guy? And there I go. And I'm like, okay, well let's see what's happening here. And it's usually high levels of psychological distress that are not considered kind of acceptable or they don't know how to express them, not something in their cultural background or familial background that's okay with being expressed. So instead of expressing my depression and social anxiety, I might express myself via paralysis on my left side or epilepsy or something like that.

0:03:14 Lindsey: Fascinating.

0:03:14 Thomas: Is, I was just gonna say the same thing. It's so fascinating that that's even possible. Like, it's amazing what the brain can do. That sounds like also a very difficult thing to go through. Just speaking generally, like, are there a lot of success stories here where it's like, wow, couldn't figure out what this thing was forever. Finally, you know, track it down and it's psychological. And, you they're able to to be essentially cured? Are there a lot of those stories?

0:03:15 Lindsey: Yeah,

0:03:38 Caleb: Oh, yeah, it's very, very treatable.

0:03:41 Thomas: That's amazing.

0:03:41 Caleb: So kind of going back to my background in training, so I'm what's called a cognitive behavioral therapist. So I practice cognitive behavioral therapy, where we try to take into account how your thoughts and actions influence your emotions and vice versa. And so for those, we focus on kind of treating the cause, right? So if somebody is having what we call psychogenic non-epileptic seizures, meaning they look like seizures, but you don't have seizure activity, sensitivity, we have to do a functional analysis to determine like, okay, well, what's leading up to it? What kind of actions are you taking? What kinds of thoughts are you having? What kind of emotional state are you in immediately before in order to then kind of figure out how do we need to intervene?

0:04:26 Lindsey: Amazing.

0:04:28 Thomas: Yeah, I think I've heard too many horror stories of people never figuring out what's wrong with them that I guess I was primed to think like, "Wow, it must be impossible to fix."

0:04:36 Caleb: Oh no, not at all. Now, if you don't know what you're doing, yeah, of course it doesn't go very well with treatment, but yeah, if your able to really kind of hone in on what's causing the distress in the first place and then work on fixing that, then the physical symptoms go away.

0:04:42 Thomas: I'm

0:04:56 Lindsey: So to set us up for one thing that I wanted to talk about, do you want to distinguish for folks who might not know what the difference is between clinical psych versus related areas like psychiatry and counseling?

0:05:07 Caleb: Sure. So for clinical psychology, what you do is you go into a graduate program, a PhD program, a doctoral program that's specifically called clinical psychology. And you tend to get a master's degree in clinical psych, and then you have to do both a thesis and a dissertation, as well as a pre-doctoral internship where you're working for, you know, at least 40 hours a week for a year doing nothing but clinical work. So it's got a really heavy mix of the clinical work and the research basis with it.

And clinical psychology tends to focus on more severe mental health issues or behavioral health issues opposed to traditionally counseling psychology, which focused more on kind of like life transitions and, you know, things that most of us would go through, but we might need a little bit of assistance, whereas, you know, most of this won't go through developing obsessive-compulsive disorder or tics and Tourette's, but most of of us will go through role changes, right? So I'll get married, get divorced, switch jobs, things like that. So traditionally, that's kind of been the distinction between the two. And then psychiatry is the medical practice. So where you're going to med school, getting an MD, and then typically doing about a three-year residency in the biological treatment of mental illness, so

0:06:44 Lindsey: So that's more medications. I've

0:06:49 Caleb: That can be medications for sure, and that's kind of the, I would say, the the front line thing that most psychiatrists do is medications, but it can also be either invasive or non-invasive, kind of direct impacting the brain, so things like deep brain stimulation or transcranial magnetic stimulation, things like that.

0:07:10 Lindsey: Heard of that. So that is a real thing? I wasn't sure if that was a real thing but

0:07:10 Caleb: Oh, it's a real thing um mean it It was used primarily for things like uncontrollable epilepsy or Parkinson's or things like that. But there's been a fair amount of work trying to use DBS to target non-responsive mental health issues. So things like severe OCD, for example. So there was a lot of work in the early to mid-2000s kind of looking at doing DBS implants for OCD. We're seeing some success, but there's also a lot potential problems with going in and implanting a DBS. So it's kind of a last resort.

0:07:58 Lindsey: The the transcranial magnetic stimulation that

0:08:00 Caleb: Yeah, so the transcranial magnetic stimulation has actually, in terms of research, been around since the early 90s. And has primarily been used in a FDA-approved way for major depressive symptoms or long-term depressive symptoms and has pretty good results, especially for those folks who aren't responding to either frontline therapies or medications. But in the last few years, actually been expanded to hit other kinds of problems. So one of the companies that I consult with and do trainings for, Brainsway, so they got, I guess three years ago now, a helmet, that's what we call them because they have the big coils in them and you have to put them on your head, a helmet approved for obsessive compulsive disorder ever recently got one approved for smoking addiction.

0:08:59 Thomas: Imagining the Ghostbusters version, is there one for talking with Gozer?

0:09:02 Caleb: It's, it's not that different, honestly. Like, I mean, it kind of looks like it's this giant helmet you put on your head that's strapped to this big machine. And then we turn it on and zap part of your brain. So it's not that different.

0:09:09 Thomas: Okay.

0:09:17 Lindsey: That is nuts. So that's that's really cool, um, and I I'm not sure why I had that associated with with sort of woo in my head. Um, it has it been applied in ways that aren't legitimate?

0:09:30 Caleb: I mean.

0:09:30 Thomas: I.e. talking to Zool. It is

0:09:32 Lindsey: Okay

0:09:35 Caleb: I think that there's an an enormous range of what they call non-invasive, you know, treatments for mental health problems, and a lot of them don't have good data on them. So most of the ones you can, like, you know, buy on Amazon or from someone's website or something like that, it's like, oh, put this on your head and 10 minutes a day you'll feel great, and say, well, you're probably not actually stimulating nearly far enough to get the effects, but these I mean, these are, you know, a hundred thousand dollar machines that have very, very powerful electromagnets that you have to position just right, so as opposed to, you know, Sam at home putting it on and cranking it up and plugging into the wall.

0:10:03 Lindsey: That makes sense it

0:10:21 Thomas: Tough, how as a non-scientist it does seem like such a fine line between the actual medical science and woo. In this case, you know, like if your buddy is just like, see, you gotta get some magnets and just put them around your head, and right, where you'd be like, wow, you are not a doctor, my friend, but then if an expert's like, well, you see, we gotta get the magnets and put them right, areas of your head, it's it's amazing how close that is yeah

0:10:48 Caleb: You know, I think it's like a lot of other areas where there is kind of that fine line. You know, so if I told you or told most people, for example, that, you know, oh, hey, you've had this phobia your whole life. Well, in one simple three hour session, I can I can cure your phobia. Like that sounds kind of like nonsense. Right. And you're like, OK, sure, I've I

0:11:11 Lindsey: Sounds like you're gonna call it caleb yeah

0:11:12 Caleb: Know it does, but we actually can. Can.

0:11:16 Thomas: You just need to add the 9.99 payment plan or whatever 23 payments of 9.99 wow yeah

0:11:19 Caleb: Right. Yeah. But it turns out that it's something we can do, you know, if you're doing the right kind of treatment. And that's, I think, where so much of mental health becomes difficult for people to navigate is that, you know, just like not all physicians know how to do all kinds of surgeries, or our specialists in all areas of the body, not all mental health health clinicians practice evidence-based practice. Not all of them have expertise in every kind of problem you could have. So

0:11:35 Thomas: Yeah And you know, I, I hope it didn't sound like I was trying to uh besmirch uh good science there. I more meant it as like it must be a it must be a challenge in science communication the fact that these lines are so blurry from an outsider's point of view, it must be challenging, I would think.

0:12:01 Caleb: No, no, no.

0:12:11 Caleb: It's a huge challenge. I mean, you're not wrong at all. I think on both sides, both on the trying to communicate to people, here's what you should be doing, as well as trying to train people on here's what you should be doing because you get a lot of mixed signals or mixed information about this or someone saying oh well we did research on it and it worked and you know to the lay person or even to someone who's not really well trained and be like okay great well they said they did research okay but what kind of research who did it has it been you know vetted has it been verified and replicated which are not questions that most people would ask Yeah,

0:12:14 Thomas: Hmm. Right.

0:12:44 Lindsey: Did

0:12:52 Thomas: You know, it's a shame just again, speaking anecdotally, from my experience, it is a shame we don't hear more of these medical science success stories. Like, I feel like it's just in in the I don't know, out in the atmosphere, it feels like you just hear the negatives, you know, people who have issues that they can't fix or stories of woo. But it's when you when you talk about that curing a phobia in three hours, I don't really hear about that. Like, you know, I've never heard of somebody saying, yeah, I went to this scientist, you know, this person who has scientific training is not a woo merchant and they cured my thing. Worked great. I don't feel like I hear that enough.

0:13:26 Caleb: Which is, you know, I think partially just because of how we as humans operate, which is if something goes bad, we're going to tell more people than if something goes well. And I think part of it is also sort of the, you know, still the self stigma or the social stigma that surrounds mental health issues. So if, you know, if I go to this physician and he figures out what's going on with me and fixes me I'm going to be like, Oh my gosh, my physician is incredible. I'm gonna tell other people about that because, Hey, you might have a physical health problem sometime. But for a lot of people, if they're having, let's say obsessive compulsive disorder, or they're Having a problematic eating or they are struggling with anything else. And they go to someone who's really, really good. They may not tell anybody about that, right? Because they don't want other people to judge them for having had that problem in the first place,

0:13:33 Thomas: Sure. Yeah. Yeah. You know, that's a perfect transition to a topic we definitely wanted to get to among a million, but is around mental the health. And I was just going to relate a little mini story of kind of when I went through feeling feeling resistant to getting treatment versus kind of breaking through. I remember having a feeling of minimizing of like, well, whatever I'm going through, like, I know that person has it worse. Like I can't, I don't really know how bad my thing is.

Like, it doesn't seem bad. There's everybody has it worse. You know, I, it um, seems like I'm complaining about nothing, you know, these minimizations and a certain point I kind of realized like, well, couldn't everyone do that? Like if, if, if you look at it that way and like, you have to compare compare yourself and find who has it worse. Does that mean like you all compare each other and then only the person who has an absolutely worse can get treatment and everybody else can't? You know, I sort of like talked myself out of this logic problem of like, that's silly. I really should just see somebody.

0:15:18 Caleb: Which is all too common. And not just for mental health, obviously, but also for physical health. Well, I don't feel that bad, so I won't go. But in mental health it's often, well, you know, I'm not seeing things and hearing things. I don't have schizophrenia, so, I mean, I can't be that bad off. And it's like, well you probably can't. You're probably needing help. Everybody can use a little adjustment sometimes for them, you know, whatever's happening in their life or if they struggled with something, um, so I mean it's just like going should be just like go into the physician, but I think to this this, uh, you know, kind of false dichotomy that's plagued, uh, the Western sort of philosophy and European viewpoints and then American viewpoints of this, you know, kind of dual mind body issue, right? So like, oh well, if you're sick in the body, it's okay.

0:16:10 Caleb: It's not your fault. But if you're stick in the mind, well, you probably have something wrong with you, right? Like you've failed in some way morally, so therefore that's why you're depressed or anxious or whatever, as opposed to just seeing it as one big system, which is really what it is, and saying, okay, well if you need help with any part of the system, you should have help with that part of this system.

0:16:36 Thomas: Yeah.

0:16:36 Caleb: So, those whole mind-body dualists, you know, kind of messed us up, I think.

0:16:41 Thomas: Well, and I've, I've really, you know, made an effort to try to be open about this. And I think that a lot of, a lot more people are being open about mental health, but it's it's still tough. Like it still is hard to be out in the open about struggles because part of me feels like as much as intellectually we may get it or a lot of people may be accepting of it, it still tends to feel like maybe you're getting put in a certain basket the minute you talk about it. Like, yeah, sure, people, you know, it's okay, yeah, I get it, mental health, but by being open about it, am I now just cast into a little, you know, basket over here of people who are not all right, you know, people who are not doing entirely well. So I have this worry that, am I being thought of that way? You know, and it's still a challenge, even though I really want to be open about it. It's tough.

0:17:33 Caleb: And I think that that's what most people experience right now, honestly. There is some great data, and we actually have got a big book chapter coming out that touches on this. There's some great data showing that mental health stigma is declining in certain segments of the population, primarily those who are younger, have less and less stigma towards either seeking or talking about their own mental health struggles or supporting other people who are displaying, like, hey, I have some mental health troubles. So there is, there is good movement, and that's actually worldwide, it's not like just the U.S. It's not nearly to the same level as, you know, if someone tells me they have been diagnosed with cancer, right, it's like, oh my gosh, let's give you support, you have a problem. You say, well, I've been diagnosed with generalized anxiety disorder, people like, oh, well, have you, have you tried not worrying? It's like, oh, I didn't, I didn't think about that

0:18:35 Lindsey: You just try to stop it because it's like it's just stop it it's it's really the best approach.

0:18:36 Caleb: Right

0:18:38 Thomas: Yeah. You know how many times I have actually tried to just not be depressed? I've actually tried the hell out of that. Most of my life.

0:18:47 Lindsey: Yep. It

0:18:47 Caleb: Turns out doesn't just work that way, just like, you know, just like saying, "Oh, have you, well, have you tried not having cancer? I hear you thought about that maybe you should should try to not have habit it's like you know if someone said that the other person would be like okay you're being a giant asshole right now and we should be the same way when someone has mental health struggles.

0:18:59 Lindsey: Never occurred to me. Or

0:18:55 Thomas: No I hadn't yeah yeah but But actually there's a challenge though, because it is, it does strike me as a little bit different, because, uh, correct me if I'm wrong, and maybe this is a chance to kind of talk about this with some of these things, depression, anxiety, there are things maybe you can just do as a person, you know, like they're, they're in some ways, there are things that that would maybe be put under the heading of, have you just tried not having anxiety, you know, getting exercise, going to bed on time, all that kind of stuff, so what's the balance there of talking about that but not risking, you sounding like you're saying, have you tried not having diabetes? Well,

0:19:41 Caleb: Well, I, I, I think the problem with that kind of statement is that what you're suggesting are things that do help with depression, right? So you're not saying just try to not be depressed, you're saying, oh, let's take some of these very specific steps that we know, because your body is one giant system, will help improve your mental health. So we have great, great data, for example, showing that an exercise, regular exercise routines can help people who are depressed and they will help to alleviate those symptoms. We have great data showing that if you can regulate your sleep effectively, you have fewer mental health symptoms across a whole range of different kinds of problems. So even that, it's not just like, oh, well, don't do it.

0:20:28 Caleb: You're saying, oh, well, have you tried these small changes you could make that might help to improve this?

0:20:35 Thomas: I, I suppose I'm coming at it from an angle like, often those things that are kind of within my power, for example, are used, um, as a way to say a couple things, as a way to say, ah, don't take medication, oh, medication, chemicals, you know, uh, that do these things that you can just do, and also the sense that, like, these are things that are in your control and therefore there's like more of a personal responsibility component to it than something like cancer, for example.

0:21:06 Caleb: Well, but even with, like, let's say cancer or diabetes, like, there are a lot of lifestyle things that you can do to either minimize the effects of those or minimize the chance of developing those, right? And I think if we take more of that kind of attitude towards a lot of different mental health issues, then we would see a lot fewer problems. So if we talk talked about, for example, oh, here's some things that you can do as a human being to help maintain your mental health. The same thing or the same way that we talk about, oh here's foods that, you know, are probably optimal to eat in large amounts, ones that you need in medium amounts, and ones that you should, you now, not never eat, but you know restrict your eating for those. Same thing for, you amounts of exercise or for wearing your seatbelt or things like that, you know. These kinds of public health issues and kind of helping people realize like, hey, mental health is just another aspect of health.

0:21:19 Thomas: Sure

0:22:04 Caleb: So let's talk about it that way instead of acting as if it is some sort of distinct thing floating up around in the ether that, you know, just to sense upon us when we're morally bad.

0:22:16 Thomas: Right can you talk about the component of it though um that I've definitely encountered I don't know if you have, but the component of it where people use those things, exercise, eating right, diet, all that stuff, sleep, as sort of a way to, medication or like try to get people off of medication or therapy. Yeah, true. Do you have experience with that kind of thing?

0:22:35 Lindsey: Therapy in general, right? Yeah. Or

0:22:37 Caleb: Yeah, you'll, I think sure, you know, just like we, you know, we see people who would say things like, oh, well, if you, you if You just got more exercise, you wouldn't be so fat. And it's like, okay, well maybe on one level that's true. But at the same time, what else is happening that's causing this, right? So, know with the issue of people, for example, who are reluctant to take medications, medications. You know, I'm not a prescriber, but a lot of my patients that I work with have either in the past been on various medications or are on medications when I'm seeing them. And I think that is often seen kind of like you were talking about, seen as being kind of weak, right? Like, well, you're weak, so you got to go take this Prozac, right.

Or you just, you didn't want to work hard enough, so therefore you're to take these Xanax to calm down your panic attacks. And I think kind of the mindset of that is honestly it's not dissimilar to the mindset that a lot of people have about a lot of different physical issues, like, for example, obesity, where

0:22:58 Thomas: You

0:23:45 Caleb: It's just, again, it's kind of, you know, if you were harder working, if you weren't working the right way or doing the right things, then you wouldn't need that, so therefore it's a failing of you, as opposed to seeing like, oh, it's more of a problem with my social environment, it's problem with a lack of support around me, or, you know, maybe, uh, it is a problem at the biological level because I'm predisposed to have these kinds of issues. So for all of those things for for cancer for diabetes for for obesity, for anxiety and depression and schizophrenia and so on and so forth. And so I think that kind of, again, I think, you know, goes back to that whole, like, you're morally bad if you have these things that I consider to be bad.

0:24:16 Lindsey: Things. Do you think the pandemic has changed attitudes in this sort of like stigma related way about mental health problems?

0:24:41 Thomas: Mean Now That we're all nuts? He

0:24:42 Lindsey: Yeah, exactly. Yeah,

0:24:45 Caleb: Well, there's, I mean, there has definitely been an enormous rise in the number of people seeking mental health services since the pandemic began. And I think that, you know, I would hope that there would be maybe a little bit more empathy towards those folks who are experiencing mental health difficulties. Because so many of us experienced this, you know, isolation and worry and things like that, that were outside of our normal. So I would, I would hope that it would make people a little bit more understanding.

0:25:24 Caleb: But based on the data, I'm kind of afraid that it won't.

0:25:30 Caleb: Because, you know, we're here in the United States, you know, and sort of approaching, you know, the other side of this pandemic. And it's only been a little over a year. And in two years from now, when my friend talks about how they're feeling socially anxious or they're depressed and they're isolating themselves, Most people aren't going to stop and reflect on, how was I feeling two and a half years ago when I was kind of forced to be isolated? Because most of us don't stop and do that kind of reflection. We've got data from other pandemics in the past showing that they didn't seem to cause a big shift in terms of how people either viewed mental health or physical health.

0:26:17 Caleb: So people slip back into those kind of pre-pandemic, non-pandemic mindsets and behavioral sets very, very quickly.

0:26:26 Lindsey: We've got short memories. So I wanted to go back to something that we were alluding to earlier. So you've sort of been in the skepticism scene for a while, years.

0:26:38 Caleb: Yeah, yeah. So I mean, I've been, I would say, involved with the broader skeptic world for well over a decade at this point. I started teaching critical thinking classes in, I think, 2007 or 2008, then started, hey, it's a pretty good book.

0:26:55 Lindsey: Used your textbook. And

0:26:59 Thomas: Wrote a textbook about it I would have led with that yeah I wrote the book on this I

0:27:03 Caleb: I mean, I may have co-authored with my friend Jacques Rousseau a best-selling textbook on critical thinking published by Springer, yes, but I didn't want to sound vain. Um, so It's it's a good one, um, we're going to do a second edition sometime in the near future. So, but yeah, so I have been, I mean, I, you know, back when the Amazing Meeting, TAM, was a thing, I presented out of TAM and have been involved with, uh, Center for Inquiry and Recovering from Religion and a number of other groups for, for quite a while now. So.

0:27:15 Thomas: Will have to uh link that in the show notes wow

0:27:39 Lindsey: Part of that energy has been directed, I think, at skepticism in terms of the mental health industry. And you've written and spoken about some practices in mental health treatment that might be a little more on the woo side, but have maybe gained some traction. And so I guess to start with a broad question, and maybe we can get into some specific examples, um, how, widespread a problem do you think that is in the mental health industry, in in general, like, do you think it's just a few fringe folks that are, you know, selling those, those magnet, those magnets out of their garages or whatever, or are there certain practices that are, like, actually pretty widespread that that you would want folks to look out for, really?

0:28:20 Caleb: I, I think that, um, and this doesn't make me very popular amongst my mental health companions, the vast majority of mental health practitioners out there are not doing what we call evidence-based practice, meaning those therapies that have been shown in randomized clinical trials and large-scale research to actually help with specific problems. Now, that doesn't mean that most mental health practitioners are are terrible people, that just means that most of them don't have really great training, sadly, in how to do things like interpersonal therapy for depression or the OST, the one session treatment for specific phobias, or a lot of other things. And so, you know, one thing that, um, I do a lot of in the skepticism realm is try to help people figure out, okay, well, is this particular thing this therapist is saying they want to do with me, is it actually going to help, or is it going to maybe have a placebo effect?

0:28:35 Lindsey: So

0:29:31 Caleb: And there's, um, enormous numbers of those kinds of therapies that pop up, have become very, very popular, and then fade away, and something else takes their place. And having, having been in the field for a couple decades now, it's just a really interesting thing to see, because this new therapy will pop up and become very popular for four or five years or something like that, and then here's now this other charismatic person that came up with their own new therapy that they say is wonderful, and now they're out there doing trainings and they're, you, certifying people in this or that kind of therapy. And then five years from now, it'll be something else.

0:30:10 Thomas: I don't want to derail this but can I ask, what's the harm in, uh, just getting a placebo effect? I've always thought, like, if somebody's going to give me a pill, and it either is a real pill or a placebo, and either way I feel better, I, I don't know if I care. Or is that inaccurate?

0:30:12 Caleb: And yeah, So I would argue it's inaccurate. And the reason I would say that is because you are foregoing an effective therapy, so placebo effects tend to be pretty short-term, right? So, like, I feel better right now. I feel better immediately after I get out of my therapy session, but then I'm not making any really lasting changes. Our effective therapies are evidence-based treatments. We have long-term data on those showing that, hey, it's not like you stop coming to therapy and it stops working, it's you, you stop coming to therapy because you've made the changes you need to make, and you keep applying those changes moving forward. So, you know, it's not like, we'll just use phobias, you knows. So it's like, okay, well, at the end of this three hours, you're completely cured of your phobia and you're 100% fine. It's like, no, now you know what to do when you go out there in your world and, you know, not to avoid things.

0:30:40 Thomas: Okay.

0:31:30 Caleb: And you know how to gradually expose yourself to feared situations. And, you Know that I'm not going to die and it'll be okay. And my anxiety was lying to me. And so you then start using those things in your life. So I'll see people a relatively short amount of time, right? And then they go and do what they need to do, uh, as opposed to, hey, you either need to keep coming back year after year to see me, or now they go out and they go away and they don't come back because they realize that I'm not really all that better.

0:32:08 Lindsey: Is this a bigger problem in in clinical practice than in like counseling, for instance, because I mean, you know, you're dealing with like very different sets of problems there. I don't know. What do you think about that?

0:32:19 Caleb: So if you remember earlier, I said traditionally or theoretically, those are the differences. What we really see in the real world is that there's lots of different types of people who are licensed in various ways, So clinical psychologist, counseling psychologist, licensed professional counselor, licensed marriage family therapist, licensed clinical social worker. There's a lot of licenses. All those people, a lotof them are seeing very, very severe mental health problems, even if they're not necessarily trained in these kinds of evidence-based practices. Practices. So there's about a six to seven to one ratio of master's level mental health practitioners to doctoral level mental health practitioners.

0:33:07 Caleb: And so the vast majority of people who are providing services out there for people who have mental health difficulties are at a master's label, which is not a bad thing in and of itself. But unfortunately, a lot of master's programs don't place a heavy emphasis on evidence-based practices. Instead, they have more of an emphasis on what I call the placebo therapy effects, so humanistic, experiential, kind of existentialist, Carl Rogers type therapeutic relationship issues, which are necessary, so I can't make great work if I don't have a good relationship with my patients. They're not sufficient, right?

0:33:53 Caleb: So just having that good relationship doesn't mean that we're going to cure someone's OCD, or really help them with their uncontrollable worry or their eating disorders. We have to build on that foundation. And that's where evidence-based practice comes into play, is what interventions, what methods do we have that can help disrupt someone's oppositional behavior, that can helped disrupt someone compulsions that they're engaging in over and over again. And it's not just going to be that relationship.

0:34:29 Lindsey: But going back to, let's say, you Know, so I think that that's a great point that's in the real world, right? People might not be seeing the people that they really need to see for the for these, like severe anxiety disorders and things like that. But you know, we made the point at the, the beginning that, um, the, the point of counseling psychology is to help people with sort of normative experiences, life transitions and things like that. So for, for that, for somebody who's seeking out help with that kind of thing, right, are those, those kinds of therapeutic relationship things maybe sufficient?

0:34:43 Caleb: Sure.

0:35:03 Caleb: So, you know, when we talk about whether or not something is useful clinically, we really think about comparing our, our active treatment to two things. One is a placebo treatment, you know, kind of a dummy treatment, right? Like there's nothing active happening. And the other is to a wait list. So in other words, if don't do anything, is this problem likely to improve over time? Because of what we call regression to the mean, right. So I'm very, very upset, stressed, stressed, depressed. I go and talk to someone for three or four sessions. And then, you know, here we are a month and a half later and I feel a lot better. So did that happen because of me talking to that person?

0:35:48 Caleb: Would that have happened regardless just because of time effects or was it just a placebo, right? So I think even for those more, what you could call kind of supportive Supportive therapy issues. A lot of people are having kind of a need for supportive therapy because of other issues that aren't being addressed, if that makes sense. So dysfunctional relationships or bad patterns of avoidance or rumination that they're engaging in or things like that, which can all be addressed using these kind of behavioral change principles and principles of cognitive change that we use in our effective therapies. So, you know, if someone comes to me and they're like, Hey, I'm really stressed out because I'm, Know, changing jobs and there's a lot going on and we're going to move houses.

0:36:36 Caleb: And I'm going to say, well, that, that sounds pretty normal. Like I can give you some things to help you manage your stress if you want, but like, that's a pretty normative reaction to having a whole lot of things happening in your life. Right. I can give you some things to help with that stress, though. And it's not just going to be me sitting here and listening to you. Right. Because that's what we have friends for. Optimally, it's going to.

0:37:01 Caleb: Well, I'm, some of us, I'm sorry, I didn't mean to call you out there, there. But, you know, I would be like, okay, well, here's how to do progressive muscle relaxation. This is a nice de-stressor you can do twice a day that will help to kind of lower your overall stress level and let you cope better with that. What I'm not going to do is something like, okay, let me have, start tapping on your forehead and then on your cheeks and then on your chest while chanting a mantra. And that will make all your stress go away, which is actually one of the very popular pseudoscientific therapies out there that's called emotional freedom techniques.

0:37:00 Lindsey: For yourself caleb I think I might have heard of that, yeah, this, there's another one. So, um, you know, I've got a few friends that, that have had experience with this, with this therapeutic technique and really like it. I don't know a ton about it, but I, I've heard that it is controversial in terms of the evidence for it. Um, do you have any knowledge or thoughts about EMDR, which is eye movement desensitization reprocessing okay

0:38:02 Caleb: Have lots of thoughts and knowledge, Lindsay. So eye movement and desensitization retraining, so EMDR was developed in the late 80s by a lady named Francine Shapiro, and she initially developed it to help with PTSD, post traumatic stress disorder, and the way that she came up with the idea for this was she was walking in Central Park in New York City, and she was troubled and she was kind of stressed out, and she stopped, and there were a bunch of bees that were landing on flowers and moving back and forth, and she noticed that when she started moving her eyes back and forth, left and right, watching these bees, but back and fourth, while she was thinking about what she was troubled about, pretty soon she stopped being quite so troubled about it.

0:38:06 Lindsey: Okay

0:38:58 Caleb: And so she then took this idea and made some enormous leaps towards, well, we can probably do something like that to help with your PTSD. So what happens in EMDR is you would come in, I would get a thorough history of your trauma, and then I would have you kind about or hold in your mind an aspect of that traumatic event, and while I'm doing that I would would have you then engage in what they call BLS or bilateral stimulations. And that can be moving your eyes back and forth. That could be listening to a tone that goes in your left ear, then your right ear. That can even be tapping your left leg and then your right leg. And what Shapiro and the other adherents of this are now saying is that when you do that, you're helping to integrate reintegrate the halves of your brain to have a more kind of proper emotional processing of that memory.

0:39:56 Caleb: And then now I don't have any more problems with that traumatic event or that traumatic memory. Now this began to get very popular in the mid nineties and having a fair amount of research on it actually. And the research in pretty good research trials showed, yeah, this does seem to have some pretty good effects on PTSD symptoms. People are reporting a lot fewer PTSD symptoms after completing this treatment. And it's not just once. You come in and you do it many, many times. But around the same time, folks kind of like me, but not me because I wasn't in the field at that time, skeptical cognitive behavioral therapists, started saying, okay, well, you know what that sounds like you're doing?

0:40:45 Caleb: It sounds like you're having someone engage in what we call imaginal exposure, which is I'm exposing myself to the thoughts, the emotions, et cetera, from the trauma. And then you're just having them do something else on top of that. So we've known at this point for 10 plus years years that doing imaginal exposure can help with PTSD symptoms, and in fact it's at the core of some of our first effective therapies for PTSD, so I wonder what would happen if we did EMDR without the bilateral stimulations. And so we started engaging in what's called dismantling research, so it turns out when you do EMDR with, or when you do EMD are without the bilateral stimulations, you see the same results.

0:41:02 Thomas: Interesting.

0:41:34 Thomas: New business idea, Lindsay. Side note, find a scientifically sound treatment for something, but add, rub this crystal while you do that thing, and then market it as my brilliant cure. Yeah.

0:41:46 Caleb: And that's 100%, right? And we actually, we have a name for these, we call them purple hat treatments, and it's where you you take something yeah you take something that's very effective that we already know works, and then you just add something to it and call it new, right?

0:41:53 Thomas: Put on a purple hat yeah oh that's

0:42:00 Caleb: Like and so, um, despite that research, which a lot of it came out in the early 2000s, the MDR continued to be very, very popular and to this day continues to be very, very popular. Um, and it, you know, it's it's one of these things where it's tricky because it works, and the therapist can see change, the the clients, the patients can see change, but the problem is it doesn't work because of why you say it works, right? It works because of this imaginal exposure. It doesn't work because of the bilateral stimulations, which are considered still a core part of EMDR, and a crucial part, and everyone has to do them, but it doesn't matter if you do them or not. And so it's still very, very popular today. It's probably the most effective trauma treatment that the most people are trained in because they're very, very good marketers.

0:42:01 Thomas: Fantastic so

0:42:59 Caleb: And it's, and again, people get mad at me when I say things like this, but I have enough friends already. It's very cultish, there's like three levels of training you have to go to, and you pay a large amount of money to be trained at each one of those levels, and there's a lot of buy-in that you engage in. And again, people who don't know the dismantling research will not know that. Oh, I don't have to do those silly parts. Well,

0:43:21 Lindsey: Okay that, so that's interesting. I was trying to, I was trying to think through, like, all right, so what's the harm here if it actually does, does include this. So the harm is not necessarily for the clients, it's it's that they're they're making money on this sort of marketing thing that, you know, everybody's probably trained in in grad school.

0:43:44 Caleb: Well, not in grad school, because you gotta go to these special trainings, Lindsey. That

0:43:47 Lindsey: No no I mean I mean the part of it that's effective is probably part of of graduate training I would assume and then they're calling this yeah okay yeah well

0:43:48 Caleb: Uh yes yes sorry yeah of certain programs not all programs but then it works and people who have, you know, had not much success before in helping their client clients who have trauma histories are like, holy crap, this is amazing, like this works, and it does work, it just doesn't work because of why you're telling them it works, um which to me is is very disingenuous and problematic but I'd rather someone be doing that than tapping so

0:43:58 Lindsey: Yeah agreed so

0:44:26 Thomas: Uh let's go quickly through, through every other treatment that is like this so that we can know all of them but but now we don't have time for that should we Yeah, should we hit some, is there any other highlight that we should hit that we should know about, a purple hat treatment?

0:44:33 Caleb: We're going to be here a while Um, You know, that's, that's, I would say probably the most popular purple hat treatment. There are a lot of them that fall under the kind of the headline of what we call attachment therapies, where they take things that we know help, for example, children who have oppositional behavior, and we know from this point, like, 50 years with the research, help those children, but then they'll add on other things.

So for example, one of our most effective treatments for children to have opposition behavior is called parent management training, and essentially it's teaching the parent how to be an expert in operant conditioning for their child, and how to know what behaviors I want to reinforce, how do I reinforce those, and how do I not reinforce behaviors I don't want to see, how do I ignore those and extinguish those. It's incredibly effective, and there's a lot of attachment therapies that will do that, but then also add on other things that they say are fixing or reorienting one's emotional and kind attachment to a parental figure. At the same time, they haven't done a whole lot of research on this, and they certainly haven't been dismantling research to see, like, okay, well, which parts of these are really driving the change, because again, we could just do parent management training and we see these amazing outcomes, so why do we need to do all this other stuff on top of that. And there's a lot of that kind of stuff out there, honestly.

0:46:16 Lindsey: What are some things that people should be looking for if they're looking for a mental health practitioner that would clue them in to whether they use evidence-based practices?

0:46:26 Caleb: My, my kind of general rule of thumb is you ask someone what therapeutic modalities are they trained in, and then how are they trained in those, because it turns out that, you know, there's like 500 different therapeutic orientations out there, and there is a lot, yeah, not even making that number up.

Uh, there's a lot, um, and you know, one of the most frequent ones you'll hear people use, almost say something like, I'm eclectic, um, which means like I kind of use a little bit of all these different kinds of theories, so I'm a little but behavioral, but I'm gonna do some psychodynamic stuff, and I also, you know, throw some attachment theory in there, and usually for me, when I hear someone say that, you know, hear the words they're saying, but I hear the translation as well, which is, I don't have a sound model that I'm practicing from that guides my behavior in therapy.

So for me, I'm a cognitive behavioral therapist, and so everything that happens in the therapy room with my clients, I'm viewing through that lens, which is not really compatible, it turns out, with all these other orientations. And so, so if I'm saying, well, I'm psychodynamic, but I'm also narrative psychology,

0:46:47 Lindsey: Literally?

0:47:45 Caleb: Those things are pretty diametrically opposed. And so I'm curious how you might be able to reconcile that with each other. So I ask, what do they do? How do they get trained in it? And then how do they know that what they're doing works? And if they say, well, I've been doing this for a really long time, then you say okay, goodbye, because just because I'm doing something for a long time doesn't mean it actually works, right? If they say, well, you know, the methods and techniques that I use for your particular problem, here's the research literature on that, like, here's, you know, how long we've been doing this in terms of the research, here's what we found, here's about how much better you can expect to be at the end of this, and that's very different than saying, well, well, you know, I've been in the field for 35 years and I've seen people who have trauma for 30 years. But how do you know that what you're doing works?

0:48:42 Caleb: Are you doing measurements session to session of symptoms? Could you show me that data? Or could you show the data from the research studies? As opposed to me just kind of taking your word for it.

0:48:42 Lindsey: Yeah, that's helpful. I do Have one question. It's a little bit of a left turn, but it might be a fun place to close off. So Caleb, are you still in touch with Angelina Jovovich?

0:48:55 Thomas: Oh. Sure. Where's

0:49:05 Caleb: Not recently.

0:49:08 Lindsey: Do you want to tell a brief?

0:49:09 Thomas: This come From and catch Us up

0:49:10 Lindsey: Yeah, tell us what happened there. Not

0:49:13 Caleb: So, So, um, so I'm an academic and I, I publish a fairly large amount. Um, and any of us who have published a fairly larger amount, um. We get these, uh, predatory journals, uh, that will say, hey, why don't you come write this article for us? Hey, you know, we started this new journal. We need you to, we'd like you to contribute, contribute and they're always very polite in very terrible English you know so it's "Dear Esteemed Professor Dr. Lack", you know, they'll start out like that. No, you know, we look forward to receiving your your article on, I think the one I saw in my my trash today was like the New Journal of Dentistry. Right, like they're just spamming. Like I don't know anything about dentistry, but I could publish an article there.

0:50:05 Caleb: And so these predatory journals will send those things out. So a couple of years ago, I just kind of bored, I guess. And I got one of these from this journal that was signed by this lady named Angelina Jovovich.

0:50:19 Lindsey: A real name, I don't think.

0:50:20 Caleb: I don't know about a real name, but it's a good name. And so Angelina Jovovich asked me if I would contribute a article to their new their new new journal that was all about alternative health and practice. And I just thought, well, I can probably do that. I was kind of bored and I thought that would be hilarious. And so it was actually called Advances in Complementary and Alternative Medicine.

0:50:53 Lindsey: Your specialty.

0:50:54 Caleb: Yes, Yes, which I am. I am actually a specialist in that, but I'm a specialist and, you know, debunking and it. So, so this was in like a January, I think like 2019. So I just replied, I was like, yeah, I'd be, I'd be happy to write, happy to ride an article. They're like, okay, that's amazing. So, I sent, I send it in. And then I didn't hear anything back because it turns out they wanted me to pay large amounts of money to them to publish this. And it, it wasn't something I was interested in doing, this whole paying large amounts of money, uh, shocking,

0:50:55 Lindsey: You didn't want to debunk the, or no, sorry,

0:51:32 Caleb: Uh

0:51:32 Lindsey: Never mind. I was going to make a conceptual penis reference, but yeah, it

0:51:34 Thomas: Yeah.

0:51:37 Caleb: Conceptual or otherwise. No. So, so what ended up basically happening is, you know, they said, hey, could you send us this? I was like, sure, I'll send you something, but it will be very critical of complementary and alternative medicine. Is that okay? And they're like, well, sure, any type of article is fine. Um, and so I, I what I did was I took a blog post I had written like six years before, um, I fancied it up a little bit, know, added the references in APA format, and then submitted it, submitted as, here, here it is, and it was on this thing called induced after death communication, which is the fancy new term that people who think they can talk to the dead are using. And then a day after I submitted, they're like, all right, we got it.

0:52:26 Caleb: Thank you. And then they're, like, okay, but before we go any further, please note that there's a nominal publication fee. I was, like, all right. Okay, good. Well, I'll see what the peer review says. And so then I didn't hear anything. Didn't hear nothing. And then in like late March, um, all of a, out of nowhere, Angelina writes back to me and, uh, says, hey, yeah, uh, here's, here's your your feedback and we're gonna charge you eight hundred dollars to publish this, so here's the link to pay. Um, and then and and I always, I love the kind, the bad translation, you know, it's like, here's the link to pay, hope you understand us, you know, like, like very mafia-esque, right. Um, and so Then yeah right Uh, and so, so I was like, no, um, I'm not, I'm not gonna do that, uh, you Know, send me, send me the peer review because I'm interested in seeing what that is, um, then the peer view was literally just someone saying, uh, this work is accepted for publication, like that was literally the extent of the peer review, uh, That was it.

0:53:06 Lindsey: Does sound like a threat. Yeah.

0:53:07 Thomas: Yeah. Yeah I think I'll pass

0:53:30 Caleb: I was like oh yeah and And so, so I was like, "Well, that didn't look like much of a peer review, Angelina, uh, I hope that you can, you know, find someone to actually review it before I, I give you a payment of 822." And she's like, "Well, okay, um, we're not going to compel you to pay before the peer review process." And that was actually the word you used, compel to pay. "Uh, so we'll, we'll get you some more, uh, more, more peer review." Um, so then they sent it back for more peer-review and, uh, they said basically like, "Yeah, this is great. Um, you were kind of mean when you talked about EMDR in here, so maybe be nicer, uh, but otherwise publish it." And I was like, "Okay." And then she, uh, she was like, "Okay, so I need your 822 dollars." So again, I was just like, "No, um, I'm willing to publish it with you if you waive the publication fee."

0:53:29 Thomas: Congrats. Yeah flying colors that peer review

0:54:31 Caleb: And then he, she essentially responds back like, "Hey, no, we'll, we'll bump it down though." We'll pump it down to six hundred dollars six hundred dollars submit your revised manuscript uh which is pretty you know generous um but I I then wrote back and and told them that that was still too much um that I regret

0:54:35 Thomas: It's on sale yeah yeah want to write a number slide across the table zero dollars I

0:54:50 Caleb: Right I you know I regret we've let a little thing like money come between us and halt our relationship relationship. And then I expected that would be the end of it. But then she just keeps writing me back and just keeps saying like, oh, no, just pay it. It's fine. And we'll publish it. And so I start I start getting really, really kind of snarky at this point. Not that I wasn't already. And I pulled it up so I could actually read it because I think it's going to make Lindsay you laugh out loud. So I said, you know, dear Angelina Jovovich, thank you for your response to my response about your response. I'm afraid that I will be disappointing you again this time. The manuscript that you request will be sadly not forthcoming. It's almost as if we are now family, given the money you are demanding from me and the disappointment you are showing in me. So now I name you sister.

0:54:56 Thomas: Hope

0:55:42 Caleb: Sister Angelina, your disappointment must be great in me, I've let you down this time, um, I can only hope that you know in your grief you can find solace in the fact that other members of your extended science family will pay the exorbitant fees required by your journal, uh, and go on and go and go along. And then, uh, so she just replies, I was like, all right, thank you for your reply, um, how about 150? And I was, I was just like, well, I I appreciate your writing back. I have a Starbucks gift card with $5 on it and a Coles coupon. Can I send you to those?

0:56:17 Thomas: She waits until black friday though and it's like all right there's cyber monday maybe that's more of a cyber mondAY thing actually oh

0:56:24 Caleb: Yeah. But then, and this is my favorite part, then she's just like, fine, fine. We'll publish it for free, but you have to send us two more articles.

0:56:36 Caleb: Like we'll publish It, but, but send us to more articles and that's how that was published actually.

0:56:43 Thomas: Really they

0:56:43 Lindsey: Oh, so it is published in the journal.

0:56:44 Caleb: So it's published in Advances in Complementary and Alternative Medicine in May 2019. But then they didn't publish the other articles I sent in, which got even more critical.

0:56:55 Thomas: Just wanted to hold those over you for yeah for another uh eight hundred dollars a pop probably keep you on the hook wow

0:57:00 Lindsey: Yeah, I got to watch that saga unfold on Facebook as it it was happening, it was just the the happiest part of my life at that year uh so yeah preyed on the predatory journal it's nice ending thank you

0:57:09 Thomas: That is so funny yeah

0:57:13 Caleb: I got them back. I got back.

0:57:15 Thomas: Well we are way out of time but this This was such good, useful info. Overall takeaway message, get mental health treatment, everybody. What do you think?

0:57:26 Caleb: I think, you know, get it if you need it and you're feeling stressed and find a good, solid provider that's doing good evidence based work. All

0:57:31 Thomas: Right. All right. Well, thank you so much for joining us. I think that's really helpful and I hope people take home that message.

0:57:44 Caleb: Right. Thanks for having me on. I appreciate it.

0:57:54 Clip: Thank you so much for listening to Serious Inquiries Only. If you like the show, the absolute best thing you can do is support us at patreon.com/seriouspod. The second best thing you can do, is please share it on social media or by word of mouth. Speaking of social media, follow me on Twitter at Serious Pod. If would like to be Facebook friends, send me a request at facebook.com Thomas podcast. If not up for that level of intimacy, that's fine. Maybe you want to join the discussion at facebook.com/groups/SIO members. Thank you again for listening. We'll see you next time.