Progress In Understanding and Treating Anxiety and Related

1 The neurotic paradox: Progress in understanding and treating anxiety and related Epigram The Neurotic Paradox In 1950, O. Hobart Mowrer described a mystery: [It is] the absolutely central problem in neurosis and therapy. Most simply formulated, it is a paradox—the paradox of behavior which is at one and the same time self-perpetuating and self-defeating!...Common sense holds that a normal, sensible man or even a beast to the limits of his intelligence, will weigh and balance the consequences of his acts: if the net effect is favorable, the action producing it will be perpetuated; and if the net effect is unfavorable, the action producing it will be inhibited, abandoned. In neurosis, however, one sees actions which have predominantly unfavorable consequences; yet they persist over a period of months, years, or a lifetime. (p.486) 2 Introduction I began graduate school in clinical psychology in 1964. Now, as I write this introductory chapter I am 50 years into a stimulating and rewarding career. Thus, when presented with an opportunity by my publisher to recap the highlights of this career in the form of a strategic selection of publications I can only think that it is rare privilege and pleasure indeed for several reasons. First, is the fact that I am still here with my cognitive processes relatively intact (an observation that some would dispute). Second, this opportunity affords me the chance to temporarily pull out of the day to day demands of a busy ongoing program of clinical research as well as the usual and customary academic duties to reflect back on the major trends and developments that have occurred during the last 50 years. In addition to reflecting on these trends and any small part I may have played in developments over this period of time, the hope is, that close observation of the path and process of progress in various areas in which I have worked will be useful in providing some perspective to current and future generations of clinicians and clinical scientists on the nature of scientific advancement in our field. Accordingly I have organized this retrospective by choosing publications from four major areas. The first area focuses on fundamental methodology in clinical research, particularly in the area of idiographic, single case experimental methods in the development of psychological treatments as reflected in two papers written almost 30 years apart. The second section carries on with another major theme in my research on going for the full 50 years, the development of new treatments for anxiety and related disorders. The third section covers research delving more deeply into the nature of anxiety and negative affect with implications for the study of the etiology, diagnosis, and classification of anxiety and related disorders. In the final section I turn more towards policy with a description of the trials and tribulations of promoting and 3 disseminating evidence based psychological treatments, a process in which I have been heavily involved for the past 25 years. But before describing the publications chosen to represent developments in each of these four areas, it would seem useful to say something about my own odyssey and the intellectual and experiential influences that provided the context and, at least in part, determined the substance of my contributions over the decades. Boston: the Early Years My undergraduate years were spent in an idyllic fashion at the University of Notre Dame where I was deeply immersed in the academic and athletic culture of what was then an all-male University. But due to its strong Catholic heritage a gaping hole in Notre Dame’s academic portfolio was the absence of a department of psychology. As with many Catholic universities, those responsible for the curriculum at Notre Dame assumed that the principles of psychology were adequately covered in the myriad philosophy courses available. As it turned out, Notre Dame was one of the last Catholic universities to correct this omission. This was not terribly concerning to me at first since I loved to read and became deeply immersed in literature, including fiction but also biography. And I soon realized that the most fascinating books I encountered involve the psychoanalytic study of literary characters! With my long standing interest in how people behave (one of my less than endearing traits was setting up practical jokes to see how people reacted to improbable situations) and a perception by my friends that I was a good listener, I realized that I was very strongly interested in psychology. Knowing that I wanted to major in psychology, but also that I did not want to leave Notre Dame, I began taking advantage of psychology courses that were offered, mostly in the sociology department (my official major) and accumulated sufficient credits to apply to graduate 4 school with one exception – a laboratory course in experimental psychology. To meet this requirement, I enrolled at Boston College for an intensive course in experimental psychology with accompanying laboratory experiences during the summer of 1963 prior to my senior year. That course happened to have been taught by Joseph R. Cautela. During that intensive 6 week experience immersed as we were everyday in the classroom and lab, Cautela made an indelible impression persuading me that only through a reliance on the slow but inexorable process of science could the applications of psychological principals to human problems truly advance. This was a very different take on psychology from my initial interests in the in-depth exploration of personality and also a very different message (I was to learn) from that delivered by other clinical faculty at Boston College, who believed that the scientific method was incapable of unraveling the complexities of the human spirit, an activity that required a different more introspective way of knowing. I began graduate school in the fall of 1964 at Boston College in the M.A. program in clinical psychology. For me, the program at Boston College not only afforded me a chance to return to my home town of Boston, but also to continue working with Cautela. Cautela was an experimental psychologist as were most of the early adherents to the fledgling movement of behavior therapy or behavior modification, but he maintained a clinical practice mostly in the evenings. This was not uncommon in those days since professional and national guidelines articulating very clear boundaries between clinical psychology and non-clinical psychological training had not yet been developed; indeed, it was common for most experimental psychologists to have some exposure to applied issues during training and to engage in some sort of consulting experience in addition to academic and research duties. Cautela was very interested in what was then called “modern learning theory” comprised mostly of principles of classical and operant 5 conditioning. The previous summer, pursuing this interest in a more clinical context, he had attended a 2 week summer training institute with the South African psychiatrist Joseph Wolpe in Philadelphia. Wolpe was already recognized as one of the “fathers” of behavior therapy based on his 1958 book “Psychotherapy by Reciprocal Inhibition.” He developed this point of view early in his training after becoming disillusioned with the prevailing psychoanalytic views and, looking for alternatives, became deeply interested in the work of Pavlov. At that point Wolpe decided to do a doctoral thesis as part of his psychiatric residency, an option then available in the British system of medical training in South Africa. In a very strange twist of fate he then came under the influence of an American psychologist, Leo Reyna, who had recently received his PhD from the University of Iowa working with Kenneth Spence and who was spending a few years in South Africa, the only place he could find employment. Reyna went on to direct Wolpe’s thesis on reducing fear (in cats) through a counterconditioning process. After leaving South Africa, Reyna ended up at Boston University where he soon began mentoring another doctoral student, Joe Cautela! After escaping South Africa where he was in danger of arrest to do his strong and activist anti-apartheid views, Wolpe spent some time in England and in the United States before moving to Temple University Medical School and the Eastern Pennsylvania Psychiatric Institute in the early 1960s, where he began conducting his summer institutes. Cautela, having been introduced to Wolpe by his mentor, Leo Reyna, came back from the Institute inspired to begin administering more “learning theory” based approaches with his patients. Cautela had observed Wolpe’s technique of “Systematic Desensitization,” (SD) in which patients with phobias and anxieties would imagine their phobic situations arranged on a hierarchy based on patient ratings of 6 intensity of fear while deeply relaxed under the therapist’s direction. Patients would slowly move up a hierarchy of these imaginal situations from least fear provoking (e.g. looking at a spider across the room) to most fear provoking (holding the spider) contingent on their fear diminishing and, as the theory went, the anxiety would be “reciprocally inhibited”. In Wolpe’s view this process occurred at a very basic peripheral neurological level but, it wasn’t long before psychologists pointed out that the physiological components of the theory were not tenable scientifically, and that the process almost certainly was best described as counterconditioning. This was an important early example to me that the scientific process could, in fact, direct and guide the development of knowledge in a clinical context. In any case, following this institute Cautela became very intrigued not only with the application of principles of learning to the clinic but also with the process of utilizing images in therapy. With his background in both operant and classical conditioning (which comprised at the time most of what we knew about learning) he began incorporating behavioral principals in imagination utilizing terms such as “covert” reinforcement (imagine engaging in a desired behavior and being rewarded etc.) and “covert” sensitization (for someone with alcohol abuse, imagine engaging in a pleasurable but undesirable behavior such as reaching for a bottle and suddenly beginning to feel very nauseous with the nausea intensifying as the bottle comes closer (e.g. Miller & Barlow, 1973). He would discuss his cases during class as well as during casual meetings outside of class and it would seem, anecdotally of course, that he was achieving some considerable success with his patients. During informal conversations and private meetings Cautela would actually demonstrate some of these procedures to me. It is hard to appreciate how extraordinarily radical this was at the time, since the ubiquitous prevailing approach was psychoanalytic and deviations from this approach were viewed at heretical and even unethical. 7 Cautela went on to become one of the early presidents of the Association for the Advancement of Behavior Therapy (AABT), now the Association for Behavioral and Cognitive Therapy (ABCT), in 1972. During the summer of 1966 after finishing my master’s degree Cautela arranged for me to spend several months with Joe Wolpe in Philadelphia whose offices were at the Eastern Pennsylvania Psychiatric Institute. Wolpe ran a very active clinical unit and since he had something new and different to offer, many patients were referred who had already failed to benefit from long term psychodynamic psychotherapy or medications available at that time. As a graduate student this was a very exciting time since, under Wolpe’s supervision, we would utilize many behavioral procedures including systematic desensitization, assertive training (which was a specialized form of helping people function better in demanding interpersonal situations) as well as deep muscle relaxation techniques, then one of the bedrock strategies in behavior therapy used in SD and other applications. Visitors from around the world came to see what this new “Behavior Therapy” was about, and we would engage in stimulating and interesting discussions of these sometimes difficult cases. Once a week I would accompany Wolpe over to the main Department of Psychiatry at Temple where he would treat a patient using behavioral techniques such as SD in an ongoing seminar format in front of 15 or 20 of assorted psychiatric residents and faculty. Wolpe simply sat in the middle of a room with the patient with everyone seated in a circle around him. As the weeks went by the patient would often improve dramatically which would be surprising and even shocking to the residents and faculty deeply steeped in psychoanalytic thought who would then spend the rest of the session trying to interpret what Wolpe was doing in psychoanalytic terms. At one point after a particularly skillful session a resident approached me saying “isn’t it just the case that Dr. Wolpe is wonderful at 8 forming alliances and that this patient’s progress is simply due to the effects of the alliance and resulting transference?” Already a “true believer” I found myself replying “no” that any success could not be due to Wolpe’s skill as a clinician because we often interchanged therapists with the same patient during the course of treatment (which was true) and that it really was the new behavior therapy techniques that were important! In later years I would recount this anecdote to Wolpe and how I found myself in the position of renouncing to some extent his therapeutic skills (feeling something like a “Judas”) because, in fact, Wolpe was a wonderful, warm, and supportive therapist. The Vermont Years After an exhilarating summer studying and working with Wolpe in 1966 and newly married to Beverly Colby I began my doctoral studies at the University of Vermont. At that point in time it was very clear to me that I wanted to pursue a more scientific approach to clinical training and the nascent field of behavior therapy seemed provide the clearest path. The University of Vermont seemed an ideal setting in many ways because of the presence of a young assistant professor who himself had only begun his career several years earlier, Harold Leitenberg, as well as a young associate professor of psychiatry, Stewart Agras, who had recently teamed up with Harold to pursue clinical research. Harold Leitenberg trained at Indiana University with James Dinsmoor, who focused on operant conditioning in the animal laboratories very much in the tradition of B. F. Skinner. But Leitenberg at the time had little or no clinical experience. Stewart Agras, on the other hand, who was trained in London with a residency at McGill University in Montreal, brought a British empirical approach to psychiatry with an emphasis on careful observation and measurement and diagnostic precision that was very 9 unusual in those days in North America. What I bought to the table was direct training and experience in the practice of behavior therapy such as it was in 1966 after training with Cautela and Wolpe. Working within an operant conditioning paradigm, and, under Leitenberg’s guidance, we began pursuing what at the time was an innovative to approach to clinical research. This approach emphasized repeated measurement and functional analysis in individual participants that came to be called single-case experimental designs. Our particular contribution as a new research team was translating these designs as utilized in the operant animal laboratories to the clinic resulting in a series of early research studies such as reprinted as article number 3 in this volume (Agras, Leitenberg, & Barlow, 1968). These studies, in turn led to a paper describing this methodology published in the Archives of General Psychiatry (Barlow & Hersen, 1973) and ultimately the first edition of a book on the same topic (Hersen & Barlow, 1976). What made this research possible was the collaboration between Leitenberg and Agras (and myself) since Agras, from his position in the psychiatry department, had direct access to clinical populations and clinical facilities that was very rare those days in psychology departments. Since we were pursuing a systematic program of clinical research we managed to secure several inpatient beds in a dedicated federally funded clinical research unit that was open to the whole medical school but was relatively underutilized by other departments such as medicine and surgery. Thus, for example, the severe house bound patients described in article number 3 (Agras, Leitenberg, & Barlow, 1968) spent several weeks in the hospital participating in very intensive daily treatment along with careful frequent measurement of progress and the beginnings of some experimental analysis of treatment components. To accomplish these goals our research team, by then consisting of several additional young psychiatrists as well as 10 additional doctoral students in psychology, would meet daily for two hours going over new data as they came in. It was during in depth discussion in these meetings that the translation of basic experimental methodologies to the clinic were further developed. During this period of time research focus was not limited to what would now be called anxiety disorders such as agoraphobia (we had not yet come to recognize panic attacks or panic disorder at that point in time) but rather extended to any type of very severe psychopathology, mostly treatment resistant patients who had not benefited from other treatment approaches and who were looking for something that might be effective. Thus, in these years we published papers on tightly controlled analyses of treatments for conversion disorder, claustrophobia (Agras, Leitenberg, Barlow, & Thomson, 1969), anorexia nervosa (Agras, Barlow, Chapin, Abel, & Leitenberg, 1974), and other presentations in addition to agoraphobia. It was also the case in that period that diagnosis was an imprecise and very much undervalued activity in psychiatry and clinical psychology. The second edition of the Diagnostic and Statistical Manual (DSM-II) or the 7th edition of the International Classification of Diseases, ( ICD-7), the contemporary nosological systems, offered only very loose global definitions of disorders focused on presenting symptoms such as paranoid delusions or agoraphobia. The prevailing catch all category for most non-psychotic disorders, particularly disorders presenting with strong negative affect was “neurosis” which presumed a specific psychoanalytically based etiological process with the resulting symptoms considered only superficial and relatively trivial manifestations of that process. Because of this, patients were typically identified by sometimes unreliable descriptions of their most prominent presenting symptoms or personality features and formal diagnostic categories were widely ignored. 11 Although our intensive idiographic analyses ranged across much of psychopathology, for my dissertation I returned to my focus on anxiety by examining some of the mechanisms of fear reduction in procedures we were using at that time. Many of us in those years found a convenient analog of phobia in the very common presentation of fear of snakes among college women. Recruiting participants for the studies was very easy, and so many of us did it that it came to be said that the great snake phobic epidemic of the 1960s was all but eliminated by energetic doctoral students attempting to finish their dissertations! In my case I focused on the slippage in fear reduction during the process of desensitization that occurred when the image of the snake was presented in imagination versus in reality despite the fact that participants worked up the same fear hierarchy at approximately the same speed (Barlow, Leitenberg, Agras, & Wincze, 1969). Another study focused on the effects of actively shaping approach behavior to the snake as opposed to passively moving the snake closer to the participant who sat in a chair watching (Barlow, Agras, Leitenberg, & Wincze, 1970). But it was also during this time that I undertook what has come to be from my own personal point of view the most regrettable initiative in my clinical research career. Specifically, with my expertise acquired from Joe Cautela in the administration of covert sensitization I began treating and evaluating the effects of treatment in individuals with what came to be called paraphilias but what was then called sexual deviation (Barlow, 1974a). While our focus was mostly on pedophilia (e.g. Barlow, Leitenberg, & Agras, 1969), the aggressive behavior of rapists (e.g. Abel, Barlow, Blanchard, & Guild, 1977), and other paraphilias (e.g. Hayes, Brownell, & Barlow, 1978), included in this series of studies were participants presenting with same-sex arousal patterns with consenting adults. (e.g., Barlow, Leitenberg, & Agras, 1969). At that time homosexuality was considered a disorder in all systems of nosology and, under extreme 12 pressures from society and the associated stigma, these individuals sought out treatment; so very few clinicians even gave it a second thought. But by the mid-1970s several individuals began questioning these treatment goals. One of the first mental health clinicians to do so in a shining example of groundbreaking ethical thinking was the then president of AABT, Jerry Davison, in his presidential address in 1974. Later in the decade the American Psychiatric Association “declassified” homosexuality as a disorder, and these events began what most observers of culture regard as the most rapid shift in cultural attitudes and behavior ever to occur. Looking back on that period from today’s vantage point it is very hard to even conceive how we could not have realized the inherent conflicts in attempting to treat harmless consenting adult behavior involving love and affection. But, the lesson learned by most of us is that definitions and classification of psychopathology do not represent qualitatively different entities but rather are embedded in the continually shifting landscape of cultural values and mores and that these ethical and moral issues must be transparent, debated, and occupy a central role in all of our endeavors (Barlow & Durand, 2014). In 1969, after three years at the University of Vermont and with my Ph.D. in hand Stewart Agras had decided it was the time in his career to seek a position as chair of a psychiatry department. He invited me to join him in the search for the appropriate place with a view towards continuing our collaboration. This search was a much more difficult task than might be imagined. Although Agras had clearly been very productive in clinical research and, with his CV, would be highly valued as a chair at any psychiatry department in the country under present circumstances, in psychiatry departments and clinical psychology training programs in those days, empirical research was at best a secondary activity and at worst discouraged. Furthermore, actually influencing a mature established department in any meaningful way deeply immersed, 13 as they were, in intensive (psychoanalytic) training and clinical work would have been very difficult if not impossible. But Stewart, in the process of his search, visited a small department in Jackson, Mississippi that had few established programs and therefor was in a position to hire a relatively large number of people in a short period of time. Surprised though I was as a New Englander at the location, a visit persuaded me of the excellent opportunity that existed. Thus, in the fall of 1969 we both settled a very long way from New England in the Department of Psychiatry and Human Behavior at the University of Mississippi Medical Center. The Mississippi Years From lowly graduate student in the previous months I was suddenly Chief of Psychology in the Department of Psychiatry and Human Behavior and Director of the Psychology Internship Program (now called the Psychology Residency Program)1. There were very few psychologists on site and psychology interns had yet to be admitted. In addition, when the Chief of Psychology at the adjacent Veterans Administration hospital, closely affiliated with the medical center, moved on several months after I arrived, I found myself acting Chief of Psychology at the VA as well. With this surfeit of titles but little or no substance to the programs under my direction my first task was to continue to organize our clinical research efforts along with Stewart Agras who, although devoting a fair amount of time to administration, retained his active role in research. My second was to initiate a clinical psychology internship program, and my third was to begin to fill many of the open positions with likeminded psychologists with a strong research and scientific approach to clinical work, something of a rarity in those days. Fortunately in those very In fact, a small internship program had existed briefly in the 1960’s but had been dormant for years. 1 14 early years of behavior therapy and behavior modification several outstanding opportunities presented themselves. First, Ed Blanchard, then at the University of Georgia after having completed his Ph.D. at Stanford with Al Bandura, showed some interest in joining us to help build new programs. We were fortunate to successfully recruit him with his strong expertise in psychophysiological methods and in the emerging field of biofeedback. Second, after consultation with the central office of the VA we identified Michel Hersen who at the time was looking to relocate from a state hospital in Connecticut. With Michel’s experience and a recommendation from VA headquarters, he was quickly appointed as Chief of Psychology at the VA. Michel also became Associate Director of the Psychology Internship Program since the plan was to integrate the internship with stipends provided by both the VA and the Medical Center. Other strong psychologists recruited over the next several years into the program included Peter Miller with expertise in addictions and Dick Eisler who had been a colleague of Michel Hersen’s during graduate school days at SUNY Buffalo. And in the fall of 1970 we welcomed the first group of three interns. In addition to opportunities for research one of the very attractive features of the department under the extraordinarily forward looking leadership of Stewart Agras was the notion that psychology was fully an equal partner with psychiatry in both clinical and research endeavors. Thus, psychologists were afforded principal responsibility for patients in both inpatient and outpatient units and were on call to the emergency room for psychiatric consultation nights and weekends. As the training program began this opportunity was also afforded to psychology interns who would alternate this duty with psychiatry residents (Barlow, 1974b). It was also noteworthy that the clinical psychology internship was the first in the country 15 to orientate itself as an empirically based training program. An ad that appeared in the journal Behavior Therapy stated the philosophy very clearly: The psychiatry department of the University of Mississippi Medical Center offers an approved pre-doctoral internship in clinical psychology. The focus is on a behavioral analysis- behavior modification approach to the variety of clinical problems found in community settings, outpatient and inpatient settings, experimental preschools, and a general hospital emergency room. Diagnostic testing requirements are minimal. Applied clinical research using single case experimental designs is encouraged and taught in most clinical settings. (Vol. 4, p. 627, 1973) One of the key sentences in this advertisement was “Diagnostic testing requirements are minimal.” Thus, the program moved very far away from the prevailing mode of training focusing on detailed projective and related personality and cognitive testing of patients with results in the form of a psychological report forwarded on to the psychiatrist who would then incorporate the report into a treatment plan. In this way, clinical psychology programs within psychiatry departments operated very much as a laboratory similar to clinical laboratories analyzing blood samples. Of course objective psychological testing was conducted if indicated, but the elimination of projective testing as well as the routine “psychological battery” administered to every patient was a relatively radical move at the time that prompted the predictable backlash in the community and to some extent nationally. Early in this phase of program development I received a notice from the VA that, based on a report from a committee of regional directors of training they wished to come and investigate developments at the VA hospital in Jackson. Of course, it turned out that politics was behind this notification since one of the members of the committee was friends with the previous 16 Chief of Psychology who had, in fact, been “pushed out” by the Chief of Staff of the VA hospital who was not impressed with the way he conducted his small department. The Chief of Staff cleverly used our arrival to ask if we were going to retain this individual and, after a few brief conversations, we reported back that he probably would not fit in with our developing plans. The Chief of Staff was obviously delighted and moved him out at the first possible moment, but the blame fell on us and our new “behavior modification” approach and the customary implication in those days that what we were doing was very radically different and probably unethical. A visit from Central Office of the VA quickly dispelled any misconceptions and the recommendation was to hire Hersen as the new Chief of Psychology. Fortunately there was enough support in the psychological community that, with strong backing of the chair, Stewart Agras, the training program not only survived this and other early attacks but prevailed and flourished. With strong and effective leadership over the ensuing years it is gratifying to note that the core concepts that we established back in 1969 have been retained in the form of a broad and deep scientist practitioner model of training, and the Psychology Residency Program at Mississippi continues to be one of the strongest research oriented internships in the country. But our principal focus remained on clinical research. As Stewart Agras has observed it is noteworthy that the productivity of the whole department of psychiatry in Mississippi prior to 1969 averaged one published paper per year whereas four years later close to 100 papers per year were published (Agras, 2012). As in internship training the focus was on behavioral analytic single case approaches to clinical problems although not to the exclusion of other more nomothetic approaches. While some of this idiographic research focused on anxiety disorders including phobias and obsessive-compulsive disorders, the emphasis continued to be on 17 idiographic approaches rather than any one content area. For example, selected publications from this era included work on severe speech disorders (Pineda, Barlow, & Turner, 1971); spasmodic torticollis, (Bernhardt, Hersen, & Barlow, 1972); and, and the measurement and modification of incestuous behavior, (Harbert, Barlow, Hersen, & Austin, 1974). Research meetings continued every single day and in 1971 I was fortunate to obtain my first NIMH grant to study psychological aspects of sexual dysfunctions and paraphilia. In 1974 I was promoted to full professor of psychiatry, but some of the very radical innovations in the Department came under attack. A political fight over the control of a local community mental health center waged between the Medical Center and a community hospital provided an opportunity for some in the mental health community to rail against the evils of “behavior modification” as propagated by Stewart Agras and the faculty. During this period of somewhat nasty politics Stewart was offered a much more felicitous professorship at Stanford University relocating in 1974 where he remains to this day (early 2015) as productive as ever at the age of 85! Approximately six months later and missing New England I accepted a position as Professor of Psychiatry and Psychology at Brown University and Director of Education and Training and Psychology at Butler Hospital in Providence Rhode Island where Beverly and I, now with two children, relocated in January of 1975. The Brown Years The new chairman of the department of psychiatry at Brown, Ben Feather was trained as a psychoanalyst, as were almost all psychiatrists in those days, but also had received some training in behavior therapy and biofeedback and was interested in the variety of different clinical approaches and how they could be integrated for training purposes. As the founding chair of the 18 new Department of Psychiatry at Brown.2 Ben was creative and bright but faced a number of administrative hurdles as he attempted to build the fledgling department. First, like many New England medical schools Brown University did not “own” its own teaching hospital. Rather it affiliated with a number of existing community hospitals. The freestanding private psychiatric hospital in Rhode Island, Butler Hospital, became the principal seat of the Department of Psychiatry. On the basis of an administrative arrangement worked out between the university and the various hospitals, the Medical Director of Butler Hospital would also become the Chair of Psychiatry at Brown. But other hospitals also provided some mental health services and they had to be integrated into the larger department, no small undertaking. The Bradley Hospital was the child psychiatric hospital with its own Medical Director. Some of the other general hospitals such as the Rhode Island Hospital also had psychiatric components and potential slots for hiring faculty. But, the Chair of Psychiatry did not actually control the budgets or salary lines in these other hospitals, with the exception of Butler Hospital, requiring that any negotiations to build up the department of psychiatry depended on the personal persuasiveness of the chair and an overarching sense on the part of the hospitals that being affiliated with Brown University was a good thing. Nevertheless, conflicts soon arose over expending hospital monies on training activities since this did not generate revenues for the hospitals to pay the bills. On the contrary, it cost the hospitals money and any reimbursement from Brown University did not begin to cover the time lost. While Ben Feather was very interested in beginning to build a clinical research program with external support, he was more immediately interested in setting up exemplary training programs. He saw the internship program in clinical psychology at the Medical Center in Although a medical school existed at Brown in the 19th century it had been on “hiatus” for a number of decades until resurrected in the late 1960’s. 2 19 Mississippi, which he had visited the previous year, as an exemplar of what could be set up at Brown, and creating this internship became my first task. Having arrived in January of 1975, and with internship acceptances due to be mailed out in early February there was little time to be lost and all recruiting had to be done by phone. In those days with few formal procedures in place this was somewhat easier to do (it would not be possible today) and I was able to recruit five students mostly through contacts with directors of clinical training at universities with whom I had built a relationship while in Mississippi. Nevertheless these five students were taking a large risk accepting admission to a program that did not yet exist. The five students who comprised the first internship class at Brown in the fall of 1975 included Kelly Brownell, formerly Professor of Psychology and Epidemiology and Public Health at Yale and currently Dean of the Sanford School of Public Policy at Duke University, Steve Hayes, Foundation Professor at the University of Nevada, Reno and well known for his creative accomplishments, Toy Caldwell-Colbert, formerly Provost and Chief Academic Officer at Howard University before her untimely passing, Peter Monti, who went on to become Professor of Psychiatry and Human Behavior and Medical Sciences and the Donald G. Miller Distinguished Professor of Alcohol and Addiction Studies at Brown and ran the internship program himself for a number of years, and Carol Landau, who became Clinical Professor of Psychiatry and Human Behavior and Clinical Professor of Medicine at Brown. I was also fortunate to be able to recruit my colleague from graduate school days at Boston College and the University of Vermont, John Wincze, then at Dalhousie University, to become chief of the Providence VA Hospital and Associate Director of the Psychology Internship. John remained at Brown for the rest of his career. His son Jeff would later become one of my doctoral students. 20 With a heavy focus on training, a number of publications from that period of time focused on the integration of science and practice still something of a new endeavor from a more practical point of view (e.g. Barlow, 1981; Barlow, Hayes, & Nelson, 1984). Research on sexuality (e.g. Abel, Barlow, Blanchard, & Guild, 1977) and anxiety (e.g. Barlow, Mavissakalian, & Schofield, 1980) continued at Brown as well, but research productivity diminished somewhat due to heavy administrative responsibilities. The Chair of Psychiatry, Ben Feather, unexpectantly resigned in the summer of 1975. Thus, for a period of four years the several of us who were department heads at the hospital were responsible for both the administration of the hospital while another group of us ran the Department of Psychiatry. But it was the hospital, with its large budget and the myriad of issues attendant with its mission that consumed most of my administrative time and effort. This left less time for research than was desirable from my point of view and in 1979, with the internship program firmly established, but the politics in the department continuing to be unsettled, it seemed time to relocate to a setting that allowed a more complete focus on clinical research. This decision was solidified by the arrival of a new Chair of Psychiatry from Canada of whom those of us on the search committee knew less then we thought we did. He proved to be a difficult, autocratic chair who, in addition, was not supportive of psychology. Within the year all of the full professors and chiefs of psychiatry recruited by Ben Feather at the various hospitals had left, and it was time for me to move on also. Thus, in the fall of 1979 I accepted a position as Professor of Psychology at the State University of New York (SUNY) at Albany joining my old friend from Mississippi days, Ed Blanchard who had been recruited to rejuvenate the clinical psychology program at that university two years previously.