I would like to share a very important article that was published in the New York Times a few days ago. It is called “Psychotherapy’s Image Problem”, and was written by Brandon A. Gaudiano of Brown University.

big pharma vs small therapy

Here is a brief summary of Dr Gaudiano’s main points:

  • The number of people using psychotherapy alone for mental health problems is dropping, while the number of people using medication alone is increasing
  • Recent trials show that therapy is more effective in the long run than medication for many of the most common disorders
  • Why are fewer people seeking psychotherapy? The author suggest that the profession has an “image problem”. In particular:
    1. There is no “Big Therapy” lobbying group to promote the field. On the other hand, Big Pharma has deep pockets to aggressively market their drugs
    2. Many practitioners are not using evidence-based therapies, giving the field as a whole a bad repuation
  • If we do not promote treatment guidelines that are firmly supported by evidence, psychotherapy risks being sidelined in the future

I highly recommend reading the whole article:

http://www.nytimes.com/2013/09/30/opinion/psychotherapys-image-problem.html

Fjola

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

We’ve been very busy at AI-Therapy over the past few months. In this post we will summarize some of the new developments.
 

Icelandic TV Appearance

I was interviewed for the evening news in Iceland a few weeks ago:

Fjola on the Icelandic news

 

During the interview I gave a demonstration of AI-Therapy’s social anxiety treatment program, and announced our new program in development called Overcome Fertility Related Stress (see below).

 

Fertility Survey

I have started working on a new treatment program for people who are struggling with the emotional aspects of conception and fertility problems. I’ve created a survey, and the information I gather will be used to ensure that the program is helpful for a wide range of people:

http://www.ai-therapy.com/treatments/fertility/

Those who participate in the survey will be given the opportunity to be beta testers for the program when it is ready.

 

AI-Therapy Site License for Clinics, Therapists and Other Organizations

Site licenses are now available for our social anxiety treatment program. More information can be found here:

http://www.ai-therapy.com/therapist-and-clinic-site-license

 

Overcome OCD

Ross Menzies and I are developing a treatment program for people who have Obsessive Compulsive Disorder. If you would like to be kept up to date on this project, please register your interest here:

http://www.ai-therapy.com/treatments/ocd/

Fjola

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

Last month I attended the 7th World Congress for CBT in Lima, Peru. Conferences are a great way to get up to speed on the latest developments in a field, and this conference was no exception. Overall, the presentations made me very optimistic about the future of online therapy. There is a lot of exciting and encouraging research being conducted.

As part of a symposium on internet-based treatment, I presented some of the latest results from AI-Therapy’s Overcome Social Anxiety program:

Dr Fjola Helgadottir presenting AI-Therapy overcoming social anxiety at the CBT World Congress 2013

Investigation into real world treatment data

My presentation was somewhat unusual for an academic conference in that it was based on real world data. Typically, talks are based on carefully controlled trials. There is an important reason for this – one goal of a trial is to make the results reproducible by other researchers. This is a key aspect of scientific research. However, there is an important question that is often ignored: will the results translate into the real world? The real world is chaotic, users are not screened, users are not monitored, there is less control over the equipment used, etc. In the past it has been found that treatments that work well in a laboratory environment cease to have the same impact when they are released to the general population. One goal of my talk was to present data from a commercially available treatment program, and contrast this with the latest results from academic systems.

 

Visitors to the AI-Therapy website

Before continuing, I should mention that all AI-Therapy users are anonymous, and their results are kept strictly confidential. The only data I presented are aggregated, showing average scores across groups of users.

As can be seen in the slide above, we have had almost 20,000 unique visitors to the website since our launch about a year ago. The top 5 countries for visitors are:

  1. USA
  2. UK
  3. Iceland
  4. Australia
  5. Canada

These results are roughly what I would expect. The US is our largest market, but a significant margin. The reason Iceland has made the top 3 is due to some media coverage we have received there.

 

Effective social anxiety treatment

In order to assess the efficacy of the Overcome Social Anxiety program, I determined its pre-post effect size. When using the program, users fill out a series of questionnaires before starting, and the same questionnaires after completion. The effect size is a standardized measures of the reduction in symptoms over this period (see this page for information about effect sizes, and effect size calculators).

The effect size for the first 19 people who completed all sections of the program was 1.7. An effect size of 0.2 is considered small, an effect size of 0.5 is considered medium, and effect size of 0.8 is considered large. Therefore, an effect size of 1.7 is very large. (It is important to note that this value has been calculated based on people who completed the whole program, and does not include people who started the program, but did not reach the end. We intend to write up a more detailed analysis, and release it as a white paper on this site. Please watch this space.) The primary conclusion is that online treatment programs for social anxiety can be an effective treatment strategy for real world patients.

I am already looking forward to the 8th CBT World Congress, which will be held in Melbourne Australia in 2016. I look forward to seeing the advances that will be made in the online therapy field over the next  three years!

Fjola

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

 

A recent study says “yes”!

Online therapy is an active and growing area of research in clinical psychology. In fact, there was a symposium devoted to the subject at the recent World Congress of CBT in Lima, Peru (which I was honoured to be a part of – to be covered in a future blog). Perhaps the most important question that researchers are trying to answer is: “Does online work as well as face to face therapy?”

This is a difficult question to answer since there are so many hidden variables. In fact, there is no universal answer, since it depends on the particular online system being examined, and the skill level of the therapists involved in the study. A better questions is “Can online therapy work as well as face to face therapy?” In other words, are there any online systems that can match the results of live therapists for a specific problem? According to a recent publication, the answer is “yes”!

A team of researchers from the University of Zurich published the following paper:

  • Birgit Wagner, Andrea B. Horn, Andreas Maercker. Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial. Journal of Affective Disorders. July 23, 2013. (see this link for more information)

Can online therapy be as good as face to face therapy

The authors conducted a study involving 62 people with moderate depression. Half of the patients were treated using traditional CBT in-person techniques, and the other half were treated online. The authors found that at a three month follow up, the patients who were treated online had fewer symptoms of depression than the control group. In other words, the online treatment program actually performed better than the face to face therapy.

 

Advantages of online therapy

I have discussed some of the advantages of online therapy on this blog and in my publications. These include:

  • Clients can progress at their own pace
  • Clients have a complete record of their treatment, which they can revisit at any time
  • “Therapist drift” is a known phenomenon, where therapists move away from the best practices of a particular treatment over time. With online treatments, it is easier to enforce a consistent treatment, with the correct “dose” of clinical content delivered during each session.

Of course, online therapies have challenges of their own. In particular, it is more difficult to adapt the treatment towards the individual symptoms and needs of the users without therapist involvement. In fact, it is this problem of individual personalization that AI-Therapy’s social anxiety program attempts to address.

More studies are needed to fully investigate the strengths and weaknesses of online therapy. However, the study above adds to a growing body of evidence that online therapy has tremendous potential, and will play an important role in the future of mental health treatment.

 

Fjola

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

 

Earlier this year I presented the Overcome Social Anxiety treatment program to my colleagues in the Department of Psychiatry at the University of Oxford. One of the questions from the audience was: How do you diagnose social anxiety in order to treat individuals? My answer: I don’t.

 

In the last blog I discussed the controversy around the new DSM-5. The goal of the DSM is to define the criteria for a formal diagnosis. In other words, it helps a practitioner determine whether or not person X has condition Y. I pointed out the shortcomings of this approach. In particular, the severity of a mental disorder is best measured using a continuous scale, rather than a binary classification.

 

A DSM diagnosis is important in a situation where a patient may be prescribed medication (recall that the DSM is published by the American Psychiatric Association). Most drugs have negative side effects, and they carry the risk of addiction. Therefore, taking medication for mild or moderate cases may not be a good idea. In this case, the DSM plays a vital role in determining who receives treatment. The DSM also plays a crucial role for clinical psychologists, as it guides the diagnosis and treatment of patients.

 

The situation for online self-help is different. For example, consider our Overcome Social Anxiety program. At the start of the program each user completes a series of standardized questionnaires (e.g. the “Fear of Negative Evaluation Scale” and the “Depression, Stress and Anxiety Scale”). The goal of this assessment is not a diagnosis. Rather, the goal is to determine where the user falls on the social anxiety spectrum prior to treatment. After the user completes the treatment program, they fill out the same questionnaires. The results are compared to the user’s pre-treatment results to see if their symptoms have improved.

 

We don’t require a diagnosis to use the program since people from along the whole social anxiety spectrum, from mild to severe, can benefit from treatment. The program uses online cognitive behavior therapy (CBT), which is known to be helpful in a wide range of cases. CBT involves revisiting thinking styles and behaviors. Unlike drugs, there are no negative side effects of CBT. Therefore, it can help everyone make better choices in their day to day life. This typically leads to an overall improvement in happiness and confidence, regardless of a DSM diagnosis.

 

Fjola

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

How are social anxiety and depression related?

Social anxiety and depression often occur together, and research has shown that targeting social anxiety can lead to an overall increase in mood and happiness. In this blog we look at an example of how the two can be connected.

Waking up with anxiety

A thought pattern that can be a contributing factor to depression is rumination. Let’s consider the following scenario: you’ve been to an evening party, and the first thought that pops into your head the next morning is “Oh no, did I really say that? I wish I hadn’t – I may have offended someone.” You continue to dwell on the thought, and over time your feelings of anxiety amplify. Eventually, you convince yourself that it was a terrible scene, and you become angry and upset.

Rumination following social situations is a common symptom of social anxiety. The social anxiety is leading you to (a) set unrealistic expectations for yourself, and (b) over-analyze the event after the fact. By targeting social anxiety, you will be less likely to ruminate, and therefore spend less time being self-critical.

As a side note, this is consistent with the results that we are observing with our social anxiety program. In particular, there is a (statistically significant) decrease in symptoms of low mood for those who complete the program. Dealing with social anxiety can have follow-on effects that lead to a happier, more fulfilling life.

Fjola

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

 

One of the things I love about living in Oxford is all of the great museums around. The closest museum to my house is called the Pitt Rivers Museum, and it has the most unbelievable collection of, for lack of a better word, stuff I’ve ever seen. One section that always interests me is called Amulets and Charms, and it contains thousands of artifacts that someone at some point in history believed had magical powers. The exhibit always reminds me of how deeply we desire to feel a sense of control over our lives and environment.

The desire to feel in control is part of the human psyche, and has wide ranging impacts.  For example, many people who suffer from depression feel that they do not have enough control over their lives. In contrast, many people suffering from anxiety problems try too hard to control every aspect of their life. In this blog I’m going to take a quick look at some research I have been involved in.

 

Control and anxiety

Does knocking wood help?

Superstition is an example of one way we can increase our feeling of control. For example, if you knock on wood after saying something you hope doesn’t happen, the superstitious belief is that the act of knocking of wood will magically influence the outcome of a future event in the real world.  Regardless of whether or not you actually believe in magic, if you conduct this ritual enough times it can lead to a pattern of learned behavior. If the undesired event does not occur, you may feel like you have contributed to the outcome, even if it was completely outside of your control. Therefore, you get a small reward for knocking on the wood, which reinforces the behavior. In the long run, this can create the illusion that you are responsible for things you have no control over. In some cases this can help maintain a form of anxiety known as obsessive compulsive disorder.

Superstition and obsessive compulsive symptoms

As mentioned above, over time superstitious behavior can lead to people believing that they can impact the outcomes of events which they actually have no control over. As a result, some people develop a strong sense of responsibility. For example, someone may have the obsessive and intrusive thought “if  I don’t knock on wood, something bad will happen and it will all be my fault”. This thought is an example of magical thinking, since magic is needed to explain a causal relationship between knocking on wood and an unrelated future event.

Several studies have observed a correlation between magical thinking and obsessive compulsive thoughts. Given this relationship, my PhD supervisor Ross Menzies and his colleague Dr Danielle Einstein had a new idea. Would it be possible to treat obsessive compulsive disorder by targeting magical thinking? The idea is as follows: if someone truly understands that there is no way that knocking on wood will impact a future event, they may be less likely to engage in the compulsive behavior. We took a look at this idea, and our early results indicate that there is some promise to this approach.

 

References

Danielle A. Einstein, Ross G. Menzies, Tamsen St Clare, Juliette Drobny and Fjola Dogg Helgadottir (2011). The treatment of magical ideation in two individuals with obsessive compulsive disorder.  The Cognitive Behaviour Therapist, 4, 16-29 

Fjóla Dögg Helgadóttir, Ross G. Menzies and Danielle A. Einstein. (2012). Magical thinking and obsessive–compulsive symptoms in Australia and Iceland: A cross-cultural comparison. Journal of Obsessive-Compulsive and Related Disorders, 1. 216-219

Coming up: Paper at the World Congress of Behavioral and Cognitive Therapies WCBCT 2013, July, Peru, Lima. Title: Superstitious behaviour in Iceland during and after the global financial crisis simulates the aetiology of obsessive-compulsive disorder. More…

 

fdh

 

Fjola  Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety