Ken Huey 0:00

Welcome to The Voice of Hope, where bold leaders and healers share how they're building hope, not just talking about it. I'm Dr. Ken Huey. Let's meet the changemakers transforming lives from the therapy room to the boardroom. Today's guest is Dr. Harry Volgorakis, a licensed psychologist, BCBA D, and assistant professor at St. Joseph's University in New York. He's a leader in neuropsychology, behavioral analysis, and process-based therapy, known for helping clinicians and organizations make sense of brains, behavior, and ethical practice. He's also a consultant, researcher, and nationally recognized educator shaping the future of behavioral health. Harry, thanks so much for being with us. Yeah, fantastic. And we'll have you. Not all of our listeners will know some of the acronyms, so I'll have you tell us what those are and stuff as we go along and uh just kind of discuss. So you've been pulled into an intersection of neuropsychology and behavior analysis. These are not two worlds that play together really well at times. What happens that got you into something that doesn't always speak the same language well?

Harry Voulgarakis 1:09

It's a good question. And I should preface it by saying that a good chunk of my work for many years has been with folks with autism, developmental disabilities, cognitive intellectual challenges, and so forth. And my first experience really, uh my master's was in special ed, and I became a behavior analyst that way. And so I was working in a school setting with folks with many of the diagnoses that I just mentioned, from young children all the way up through the adults in the transition program. And so behavior analysis, just by virtue of what it is, is more on the intervention side of things. Neuropsychology deals a lot with assessment. And so you definitely see neuropsychology principles applied in rehab settings and so forth. But by and large, as a profession, neuropsychology deals with assessment and diagnosis. And so those two things, you're right, often don't communicate or happen in the same place sometimes, especially with children. So they will get a diagnosis, they'll see an evaluator who conducts, assigns a diagnosis, and then that report sort of gets handed off to the treatment team, which in my case was the behavior analyst. But for sometimes with children or adults, it could also be a speech pathologist, an occupational therapist, a physician, psychiatrist, what have you. And so as I was sitting on that intervention side as the behavior analyst, sort of seeing all of these reports coming in, my curiosity grew. And I think I was left unsatisfied, wanting to know more about uh how the brain works, how kids get or don't get uh certain disorders, which is still a question that we can't quite answer, right? So I think that's really what wanted me to go back to school, become a clinical psychologist, train in neuropsychology, and really get some answers, I think, to some of those questions, like how is a diagnosis constructed? Where is this data coming from? How do you rule things in and out? What does a cognitive profile mean? How does that relate to intervention, treatment, all of that stuff? So curiosity really I think pulled me into neuropsychology.

Ken Huey 3:04

All right. So that kind of touches on a question I have for you, but everybody has a why. The the thing that gives them joy, that brings them into the job, that they've got hopefully, and not just going through drudgery. What is your why? Why this?

Harry Voulgarakis 3:17

I think every job that I've had has been in a service profession. Uh, and I come from a family of helpers. My parents have always worked in in the helping professions. My sister's a nurse. I've always done things sort of oriented. So that might be a socially reinforced thing in the family system. But it's also something that I think as I've grown in in my career, just getting that reinforcement of being able to see how you can impact somebody's life uh is really meaningful. And then I think some of us just get jobs, and once you land in a job, that kind of starts shaping your career. Yeah. So one of my first jobs uh was as a camp counselor, uh, working with kids. And I was kind of drawn to the kids with special needs or the ones that other people found, you know, quote unquote difficult or whatever that might be. And so from there, you know, came other jobs, and from there came graduate school. And so I think it's a long sort of shaped why, or or the why kind of gets shaped by by the experiences sometimes.

Ken Huey 4:13

All right, talk to us about, if you would, ACT and RFT. What's that stand for?

Harry Voulgarakis 4:19

Yeah, so we pronounce it ACT, and it stands for acceptance and commitment therapy, and it's a therapeutic orientation. And so for listeners that are kind of in the therapeutic space, if you've heard of CBT or EMDR or CBTI and IFS and all of these, these initials, right, for different kinds of therapeutic models and orientations. ACT is one of those models we call it, or it's considered to be the third wave of CBT. And so it's derived from cognitive behavioral principles, except it treats some aspects a little bit differently, integrating more of the acceptance and mindfulness traditions in with some of the behavior analytic components. It's actually a behavior analytic in tradition. Relational frame theory, RFT, is the theory of language and cognition on which ACT is based. And so part of what I really love about ACT is that the developers didn't kind of wake up and say, we want to come up with a treatment for trauma or a new methodology to treat this problem. It was really about what are the core components of human change, what keep people stuck, what are facilitators of change, what are the processes that help move people in a direction of things that are important to them. And so RFT is the theory of language and cognition that sits underneath it that I can go into a little bit more detail, although I will say it's it's somewhat complex, but ACT is the application, which is a very cool and I should say extremely well-researched therapeutic method that's designed to be transdiagnostic. And so it's not a treatment for trauma or a treatment for depression or a treatment for anxiety, although it can do all of those things. And in particular, it's been really effective at treating things like chronic pain or an adjunctive treatment, I should say, for chronic pain, all the way through uh organizational behavior change, um, school-based behavior change, all different kinds of applications.

Ken Huey 6:09

So cognitive behavioral therapy, CBT is, of course, well resourced and evidence-based. Fine. Act and RFT and process-based models are also very much evidence-based. Tell us what's one distance section about evidence-based practice.

Harry Voulgarakis 6:24

I think a big misconception about evidence-based practice, or or EDP, I'll call it, is that a lot of people think it means following a manual uh that is prescribed by a particular treatment protocol as written. And so if you're treating depression, you need to be using a, you know, a depression manual or something, or something that only says that the research is for this or that. And that's just simply not what it means. Uh there's been task forces, there have been papers, there have been books. Um we can really narrow down EBP to three components, integrated components, I should say, the best available research, the clinician's expertise, and then the patient's values and context. And very often the last two kind of recede in favor of the first. And so we're very much stuck in sometimes, you know, the practice or the treatment for this or the protocol for that. And we forget that the clinician experience and expertise and the patient value and context are just as important. And so in ACT and in some of the broader process-based models, we emphasize uh the unit of analysis as the functional process that moves away from kind of have you delivered this with fidelity? Did you deliver session four correctly? Did you make sure you started the exposure protocol today? And instead, it becomes more about targeting a particular process. Like, do I need to gain a little perspective here? Do I need to open up to some hard feelings and facilitate acceptance? Do I need mindfulness to kind of back off from my thoughts a little bit? Am I being intentionally rigid in the moment? And so when we can start to look at processes and then look at how the person responds to that process, that's a real component of an evidence-based practice. And if I could just say too, that I think this misconception that it's only the best available research and the protocol that's available, that misconception shows up in two ways. One of which is, of course, over-manualization, believing that any deviation from a protocol is going to somehow invalidate the work or make it ineffective. And the second is over-relativism. And that's kind of leaning on research-based findings, like, oh, uh, as long as I'm a supportive, caring therapist and we have a good therapeutic relationship, then change is going to happen. And so then it's kind of like as long as I'm here and show up, then then anything goes and that's helpful too. And that's not the case either. So true evidence-based practice really kind of lives in the middle. It is disciplined, but it's flexible. It's structured, but it's contextual. It's contextual to the person.

Ken Huey 8:49

So you voiced some pretty strong opinions about ethical scope in autism evaluations. What moment made that issue feel impossible to ignore?

Harry Voulgarakis 8:57

I think it was when I started to see or perhaps feel like, based on what I had seen, well, two things that autism evaluations were being commoditized, and that the quality of them were being sacrificed to expedite the process. And both of those, I think, are separate but intertwined issues. As neurodiversity, autism, we know the federal government that's talking about autism. We've never seen it have this much attention, I think, in the media, um, in government, and in the public eye. And that has triggered a large number of people to question whether or not their children or they themselves may be autistic. It has increased awareness quite significantly. And that has led to more referrals for autism-focused evaluations. And that's a positive thing by and large. But what that also means is that wait lists are extremely long. People are finding different ways to kind of circumvent some of those processes. And that's what's been starting to happen a bit is that people who are not fully competent, don't have all of the training to fully conduct an evaluation, are starting to do them, either to make quick money, to filter them into a treatment and ABA, applied behavior analysis, an ABA treatment program, for example. And so we're starting to see folks that either are licensed, like a social worker psychologist that's kind of jumping into the autism assessment realm now with very little training. And more concerningly, we are seeing people who are on the intervention side of things, like the behavior analysts and speech pathologists sometimes kind of pushing to saying, well, we should be able to diagnose autism too, so that we can help expedite these wait lists. And that is a real problem. You know, that there's some real downstream consequences to that. On a basic level, some children can be labeled as autistic, kind of based on narrow tools, narrow assessment measures without a broader differential consideration. Executive dysfunction, trauma, intellectual disabilities, anxiety can all look like autism in certain contexts. And so, unless somebody has a real background in child development and developmental pathology, it's concerning to me. And so I think we we're starting to see, and some people are very well-intentioned. Let me go take this weekend workshop so that I can give this autism measure and now I can help get this child into services faster because we do have really long wait lists. So I'm certainly not saying that, you know, everybody's just out here trying to make a quick buck and, you know, shortcut things. I do think some people are very well-intentioned, and yet there are still consequences and that we're seeing.

Ken Huey 11:32

Yeah. What's the link between vaccines and autism?

Harry Voulgarakis 11:37

Uh there is none. Here's what I will say. We know with certainty that autism has a genetic link. I think narrowing down, and I'm not a geneticist, and so uh I may have to defer any further questions on this, but um, I think narrowing down exactly where it is in the genome or all of that is still something that's unfolding. We do know that it is genetic, and we do know that it's a gene-environment interaction. And so I think there are a number of studies out there that have shown uh correlation between environmental factors and autism in certain groups of people, different places, things like that. None of those correlational studies are enough to give us a causal factor. And so I think the best that I can say is that there are probably a number of environmental factors that might trigger a genetic predisposition to autism. I do not think that vaccines are one of them.

Ken Huey 12:29

Fantastic. Thank you. Curveball, off script. I just I was like, I want to promote that anywhere I can. It's like, can we stop with the madness? But okay. Okay. Uh so in your work with clinicians and organizations, what's the skill that you think is most missing in today's behavioral healthcare system?

Harry Voulgarakis 12:47

That's a great question because I I also kind of straddle the education and the training space. We need more healthcare professionals. We need more well-trained people on the front lines being able to actually, you know, support individuals. Um, what that means, though, sometimes is that we're looking at accelerated training programs and all different models. And what I have found, unfortunately, that I think sometimes then gets lost in that process is formulation. Not necessarily technique. It's not even knowledge, but I do find that sometimes today's workforce, especially on kind of the therapy side and in the mental health space in general, is being able to really construct a coherent functional formulation that integrates things like data, context, mechanisms, the person's culture, their history. I see clinicians who can, you know, administer tests flawlessly, they can follow protocols and do great kinds of things. But I really think there's value to kind of rewinding to our graduate school days and sitting and kind of writing up a quick analysis of what are the symptoms, what is the diagnosis, but more importantly, how is this person's life, context, behavior, environment maintaining this kind of system? And that work, when I sometimes sit and give myself homework for my practice and make myself do that, I'm like, oh wow, there's a lot to look at here. And so formulation is a little bit different. Um, I think it really requires synthesizing all of the factors together in the same way that we do assessment. And this is why I do think of assessment and therapy as not always totally different, but being able to look at developmental history, learning history, contextual factors, what their coping strategies and their avoidance strategies are, what their biological factors are, and then bringing that into the room. I think that that level of thought. And to be fair, some people are seeing a lot of individuals in a week. We don't have time to sit and network graph every single person's responses. But I think that that level of formulation is something that's that's missing sometimes.

Ken Huey 14:50

Aaron Powell Harry, you've published research on everything from neurodevelopment to obesity. What's the research that's kind of personally changed the way that you work, what you do?

Harry Voulgarakis 15:00

I've researched a lot of areas, you're right. Uh assessment, access to care, family functioning. I think that collection of research, and it's research that I continue to do, that's very much my focus on my research world, is that health and ability and disability are extremely complex and deeply interwoven. And a diagnosis doesn't exist in isolation. And I think that when we think about functional outcomes, when we think about what's important to children, to families, there are real barriers to effective diagnosis and intervention for people in this country, around the world. And that's not a controversial thing. That's an observable thing. Depending on where you live, depending on financial status and so forth, there might not be a specialized children's center for several hundred miles from you. Whereas we have other people in locations that, you know, can come 15 minutes up a subway or something. Families are trying to navigate layers of insurance, school systems, specialists, all kinds of policy. They need to figure out the difference between a psychologist and a psychiatrist and a pediatrician and a behavioral developmental pediatrician. And there's there's so many things that that go into this. And all of those contextual factors get piled up, but they don't get looked at when the person walks into the room and you have to start assessing and diagnosing and treating. And when that happens, you don't realize that access has already been delayed. It's already been fragmented. And so there's a whole bunch of things that you need to then kind of work through. So I think the finding that really changed me as a researcher, as a clinician, it's not something that's static, but it's kind of more of a recognition that context is so important here. I think we really need to push more research, policy, and practice that helps make basic access for everybody something that we can work toward, but especially for young people.

Ken Huey 16:54

What's the biggest shift happening right now in behavioral science that practitioners just aren't ready for?

Harry Voulgarakis 16:59

Well, I'm very much in the act and the process space space. So this might kind of be a little bit of my bias here, but but I will say, even in the CBT research, in the integration and psychotherapy research, we are quietly rethinking and I think asking important questions about how much of the human condition we've medicalized. I don't think it's a secret to anybody that lots of people end up in various layers of mental health care following the death of somebody, for example. Chronic grief after a profound loss is a human experience. But again, given context, history, environment, that's going to impact people differently. And if you can't go back to work in three weeks or two weeks, or sometimes less than that, then there's problems. If you can't get out of bed, then all of a sudden you meet criteria for all of these different things. And that I think is something that we we need to think a lot more about. I'm not saying that that person doesn't then need help or support. And it's not that treatment isn't then valuable, but I do think we're thinking more about how we diagnose people, what we consider pathology. And again, can we kind of get out of this categorical manualized treatment and start thinking more about precision a little bit? How is this person constricted? What's amplifying it? Where can they expand? That's what I think is is important on the treatment side of things that we're starting to hear more about.

Ken Huey 18:24

Harry, you're a scientist. And I'm betting you've had a belief earlier on in your career that that your work has just disproved. Give us an example of that.

Harry Voulgarakis 18:34

I don't know that it's maybe a whole belief. Well, maybe it is. I think so. I'll I'll give you a principle, actually, or it's really more of an implementation thing. Early in my training, so in behavior analysis, we talk about extinction. Extinction was often presented as like the most universal solution to a problem behavior. And so when you identify the reinforcing factor, what keeps that behavior going? Why does this person keep doing this? And then you try to remove that and the behavior will stop. And so if you keep ringing a bell and every time you ring the bell, somebody opens the door, you get candy, whatever it is, and then all of a sudden you keep ringing the bell and you're not getting anything anymore, you're eventually gonna stop ringing the bell, right? That's kind of a really basic example. But first, if you go every day and you ring the bell and and something happens that you like, and then all of a sudden nothing happens, you're probably gonna ring the bell a couple more times, right? Like, hey, do you hear me in there? And then you might even come back the next day and check again and ring that bell a few more times. And you might even try a third day, depending on how rigid or how stuck you might be. And some people might keep going back longer and longer. And when we work with children, we see that that's called an extinction burst. And we see that happen too. So when we implement extinction with children, sometimes the behavior gets a whole lot worse before it gets better. And so I learned really quickly that things are rarely as simple as identify the reinforcer and remove it because behavior doesn't occur in a vacuum. And extinction procedures can produce a lot of escalation and unintended consequences. So my research, my clinical work, this kind of gathering of data over the years has really taught me that behavior change is rarely about one particular thing. And I know that's kind of becoming a theme in some of these questions, but looking at humans in context and as part of a bigger network, just because you you can manipulate one part, it doesn't mean that that's always going to be what you should do or the most effective. And so I know I kind of got a little bit lost off of your question here, but I think one of one of the earliest beliefs, I guess, that I held was kind of stick in behavioral principle, identify, you know, follow this kind of specific sequence. And I think kind of where we started, the whole idea of EBPs, right? Is that that that's not always good evidence-based practice.

Ken Huey 20:56

So Harry, you know, you've you've earned a lot of awards for leadership and mentorship. What's a piece of advice you give your students most often?

Harry Voulgarakis 21:03

If you want it, chase it. Put yourself out there, create opportunities and go after them. Apply for things you're not sure you're ready for. Put yourselves in rooms that you're not quite sure you deserve to be in yet. But that's all right, because every day is a new opportunity to grow. I think you never know how one handshake, one email, one conversation can change the trajectory of your career, of your life. Most doors aren't going to open because you're ready. They're going to open because you showed up, because you knocked, sometimes twice. And I think if you want to move into a career, especially into academic spaces in research, there's a lot of very tall walls sometimes that you can't quite see around. So make yourself known, put yourself out there, try to create opportunities and go get them.

Ken Huey 21:46

Man, Harry, that is just gold. I appreciate that as a kind of final thought. So if people want to know more about the work that you're doing or find out more about you, Harry, where should they go?

Harry Voulgarakis 21:56

Yeah, if they want to hear more about my research and some of my trainings, they can go to drharryv.com. That's d-r-h-r-r-y, v like victor.com. If people are located in New York and they're interested in psychological services, and they can visit my practice. It's hmvpsych.com. That's h-m-v-p-s-y-c-h dot com.

Ken Huey 22:18

Fantastic. Dr. Harry Volgorakis, you have got a wide and deep background in the research and in the science. It's really very fun to talk to you. Thanks so much. Thanks for joining us on The Voice of Hope. If you were inspired, share the light. And remember, hope's not just a feeling, it's a force. We'll see you next time.