The Five Dimensions of Good Anxiety Treatment

An Interview with Anxiety Researcher David Barlow

Ryan Howes

Most people have plenty of reasons to feel anxious right now. Whether it’s around personal affairs, the uncertain forecast for the field of psychotherapy, or an overall unease with the current state of the world, there’s a collective and palpable sense of worry in the air. Fortunately, a few tireless souls have spent their careers trying to unlock the magical formula for anxiety treatment.

One of them is David Barlow. The author of 60 books and hundreds of articles, with almost half a century of practice behind him, he’s widely considered the dean of anxiety researchers. In his work, he’s been one of the foremost proponents of using exposure and cognitive behavior therapy (CBT) as the primary treatment approach with anxiety disorders.

When we spoke with him in 2016, in the aftermath of a polarizing election and a time of political uncertainty, he agreed to share his thoughts on the nature of anxiety and what research has revealed about the most effective treatments for it.


RH: Anxiety is among the most common issues that regularly bring clients into our offices. As an anxiety researcher, what do you make of the pervasive anxiety being reported, at least among Democratic voters, as a result of the election?

Barlow: For starters, the election results came as such a shock. And to a large proportion of people, especially students on college campuses, it was extremely upsetting. They didn’t get a chance to gradually acclimate to the reality and maybe introduce whatever rays of hope they could integrate into the developments. Polls just got it so wrong.

Even for people of my generation, who’ve witnessed a lot of unexpected, adverse events on a national scale, including the Kennedy assassination, the election was still a shocker. So there’s the sense of uncertainty about our future and a feeling of helplessness in terms of how to cope. All these things just arrow right into the core of anxiety.

RH: So will we gradually desensitize to this?

Barlow: Exposure will do its work. As with most events of this kind, barring other unpredictable factors, most people will resolve their initial reactions, like sleeplessness or feelings of horror. But some will experience underlying trauma and will have a difficult time getting over it. They’ll probably need to seek some help.

RH: How did you become interested in studying anxiety in the first place?

Barlow: I had the good fortune to work with a South African psychiatrist named Joseph Wolpe, one of the founding fathers of the cognitive behavioral approach back in the ’60s, who originated systematic desensitization as one of the first brief treatments for anxiety and phobias. Anxiety is such a common problem, but in those days, we didn’t really have any effective targeted treatments. There was no biological psychiatry, and our methods were mainly psychoanalytic, with some Rogerian approaches.

After I was fortunate enough to have worked with Wolpe for a summer, I began studying snake phobias among female college sophomores to investigate the specifics of treatment effects. A lot of my colleagues were doing similar studies, so we joked that by the early ’70s, there wasn’t a college sophomore left on campus who was afraid of snakes.

RH: What’s the difference between fear and anxiety?

Barlow: When we work with all of our clients, we have to emphasize that there’s nothing wrong with anxiety itself. It’s a perfectly normal, useful emotion. The same could be said of the somewhat related emotion of fear, although those are two different emotions. Fear is an emotion that’s activated when a threat or danger is identified and imminent. For instance, you’re beginning to cross the street and at the last second you see a car bearing down on you. That’s a real danger that’s going to happen right now unless your body kicks in with a fight-or-flight response. That response goes directly from visual cues to your emotional brain, the amygdala, so it’s quick and protective. On the other hand, the function of anxiety is to prepare us to best cope with some challenge or threat that isn’t occurring right now but may test us in the future.

Most of the time, anxiety helps us achieve a goal. We study harder for a test, or we work on our interview skills for a job interview. But if the coping steps you take to deal with the upcoming challenge don’t work, you may wind up in a continual state of anxiety or worry.

RH: What’s the state of the art in regard to anxiety treatment today?

Barlow: There are a large number of evidence-based treatments from different theoretical orientations for DSM disorders such as panic disorder, OCD, PTSD. There are so many, in fact, that’s it’s almost impossible to keep on top of it all. So seeing how many theories overlap and borrow from each other, most clinicians end up taking bits and pieces of these treatments, which can get confusing. What I’ve been trying to do with my research team is to distill the basic core principles that make these treatments effective.

RH: You’re looking into common denominators across theories?

Barlow: We’ve identified five mechanisms of action among the various effective treatments for emotional disorders, like anxiety, mood-related disorders, eating disorders, and such. We call it the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders.

The first principle of treatment is helping clients develop mindful awareness of their emotional experiences. People with emotional disorders tend to repress and avoid their own emotions. That’s a concept that cuts across demotioa lot of different therapies. The second one is developing more cognitive flexibility in your appraisal of experiences that are very emotional for you. In other words, you develop different interpretations of situations you’re finding anxiety provoking. What are the alternative interpretations for what is happening? This is standard cognitive therapy.

The third one is identifying all the types of emotional avoidance that people engage in with these disorders. For example, they may engage in subtle behavioral avoidance of their intense emotional experiences by trying to distract themselves, or changing the subject, or just getting out of the situation they’re in. What they’re trying to do is avoid their intense emotions, especially those with strong action tendencies, like the flight-or-fight response. Effective therapies teach clients different ways of handling situations so they don’t engage in those types of behaviors.

The fourth dimension involves looking at the various components of your somatic response to emotion: your heart beats faster, you perspire, you begin to hyperventilate a little bit. We teach people how to recognize and get control of those bodily responses. The last one we call emotion exposure. Depending on the problem, we have people go into their various situations or engage their emotion triggers in order to experience their emotions at their most intense. But here, the focus isn’t on exposure to the external situations or the fear cues, it’s to the emotional experience itself.

RH: That all makes sense. Did you run into any surprises as you developed this?

Barlow: Well, we were continually amazed at the variety of strategies clients use to avoid any aspect of intense emotional experience. It’s also interesting that the clients themselves aren’t always aware they’re engaging in this avoidance behavior. Often it’s implicit, or unconscious. Many individuals who experience panic attacks, for example, have given up drinking caffeinated beverages. If you ask them why, they say things like they’ve lost their taste for them. But we know mild arousal associated with these stimulants provokes anxiety. We discovered that this somatic sensitivity is a feature of all emotional disorders, including OCD and depression. So part of our treatment approach is evoking many of the somatic sensations in the safety of the therapist’s office, allowing exposure and subsequent extinction to do its work.

RH: With all your experience working with anxiety for all these years, what advice do you want to offer clinicians in treating it?

Barlow: All psychotherapists should be aware that the psychotherapeutic treatments we now have at our disposal are at least as effective as medications in the short term and more effective in the long term, because clients are less likely to relapse. They’re also preferred by clients over medications by a three-to-one margin. In fact, the National Academy of Medicine just came out with a proposal strongly recommending that the government put much more emphasis on supporting psychotherapeutic treatments, particularly the evidence-based ones. Over the past several decades, psychotherapy has taken a backseat to medication, but I think that’s changing. It’s increasingly becoming a first-line treatment. In fact, in some other places, like the UK, where they have single-payer national healthcare, it’s already become the preferred treatment.

RH: How do you respond to critiques of CBT who say it’s a Band-Aid that doesn’t go deep enough?

Barlow: In the ’70s, I heard a lot of people make that argument—that CBT is just treating the symptoms and leaving the underlying conflicts unaddressed. But there have been hundreds of studies now on clients with all manner of diagnoses showing that’s not the case. In fact, CBT clients tend to retain their gains, whether they’re suffering from severe depression or OCD. Whether or not practitioners call themselves CBT therapists, I believe that the Unified Protocol we’ve developed distills the basic effective ingredients in all the varieties of psychotherapy, no matter what they’re called.


Ryan Howes, PhD, ABPP, is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California.

This blog is excerpted from "Feeling Anxious? A Longtime Researcher Weighs In" by Ryan Howes. The full version is available in the March/April 2017 issue, Round Hole, Square Peg: If It Doesn't Fit, Don't Force It.

Photo © David Barlow

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Topic: Anxiety/Depression

Tags: 2017 | Anxiety | anxiety and depression | anxiety disorder | anxiety treatment | avoidance | best approaches for anxiety | David Barlow | DSM | exposure therapy | fear | fight or flight | New Tools & Methods | politics | ryan howes | somatic experience | somatic therapies | techniques

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Tuesday, August 27, 2019 9:24:41 AM | posted by Mary Rose Tichar
Thank you for this insightful article. I wish I had this for my clients who suffered in a similar manner after Obama's eletion and 8 years of office. How the times change, and how similar the reactions are from people on both sides of the aisle.

Saturday, August 24, 2019 10:20:40 PM | posted by Jeffrey Von Glahn
There is a third way of thinking about anxiety, besides the behavioral and the psychoanalytic. When a psychologically hurtful event cannot be sufficiently resolved at the time of its occurrence, or quite shortly after, the unprocessed sensory data is stored in a “frozen” neurophysiological state as an imprint. At a later time and under sufficiently supportive conditions, that data starts to “unfreeze” into a delayed fight-or-flight, or sympathetic ANS, reaction. If this delayed reaction has arisen in an unforced/unprovoked way; i.e. coincident with the client receiving sufficient support for his or her experiencing, it is part of a natural healing process. Contrary to what an observer might conclude, the client is not “losing control” or being retraumatized. (The forced/provoked activation of the client’s experiencing is not therapeutic. Too much unresolved stuff has been too suddenly forced up and the pain processing mechanisms are overloaded. With continuing support for the client’s experiencing, the delayed sympathetic phase reaches an intensity, determined by the ANS, and spontaneously transitions to a parasympathetic phase. This is followed by two nearly simultaneous reactions. The first is that the vital sign amplitudes drop to below the person’s baseline values. The second is that the sympathetic phase is replaced by a lack of physical tension and the fear/anxiety in the heightened sympathetic phase is replaced by an eagerness on the part of the client to understand how he or she has been affected by the hurtful event. That person’s insight is typically more profound than anyone else’s interpretation. (For a more complete discussion, see PN, May/June, 2012, or more recent articles by this author in PsycINFO.

Monday, August 19, 2019 7:53:31 PM | posted by Nancy Segelstein
There's no reason why you can't and most likely should, in most cases, use CBT in conjunction with (and after a few sessions of) interpersonal/attachment therapy. I believe that CBT alone can be a bandaid, but it becomes effective when the client's traumas (from small to large, historic to current) are processed therapeutically. In this way, insight is developed and the client can connect the dots. I believe clients take CBT more seriously when it makes sense in the context of their lives.

Monday, August 19, 2019 1:05:45 PM | posted by Tom Bunn LCSW
Why is it, when CBT ends panic in only 17% of people treated with it, CBT is represented as an effective treatment. Here is the reference about that 17%: As an airline pilot and LCSW I have specialized in flight phobia for 39 years. I tried for years to get CBT to stop in-flight panic. It did not work in turbulence. I was forced to experiment and finally developed a method - based on solid neuroscience - that now ends panic in just under 90% of my clients, both in the air and on the ground. You were sent a copy of my new book on this, "Panic Free: The 10-Day Program to End Panic, Anxiety, and Claustrophobia," and you didn't both to reply to to investigate, even though the afterword for therapists was written by Stephen Porges. Sorry, but it is really annoying when the established psychotherapy media represents an old, tired, ineffective method that every honest professional knows - or should recognize - is not effective, and ignores a new method that does do the job.

Saturday, May 13, 2017 9:45:41 AM | posted by Bill Harrison
This is a useful article but I'm amused by Dr. Barlow's assertions about the efficacy of CBT. Easily 3 out of 5 of his recommended anxiety treatments are psychodynamic. For non-endogenous anxiety, the only way to achieve 2nd order change for most patients depends on getting at the psychological roots of their particular manifestation of anxiety. That is most assuredly not the purview of CBT. This truth has been demonstrated many times not only in research but in the lived experience of countless therapists. It is, in the words of one wise analyst, practice-based evidence.