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

 

We are very excited to have arrived in Lima, Peru for the conference. The scientific program is extremely rich, so my biggest problem is selecting which talks to attend. For every hour, there seems to be about 3 interesting talk to select from!

Here we are, the co-founders of AI-Therapy, Overcome social anxiety Dr Fjola Helgadottir and A./Prof Ross Menzies:

AI-Therapy at the World Congress of CBT in Lima Peru
AI-Therapy at the World Congress of CBT in Lima Peru

I have two talks coming up. For anyone who happens to be here, please come along and say hi. Here are the details:

  • Thursday 25th of July at 9-10:20. We will speak about the latest developments in AI-Therapy, in the symposium “Latest developments in online treatments”. There will be some of the world’s leading experts on Internet treatments of evidence based treatments on the panel. Venue: Maria Angola, Room: Las Campanas
  • Tuesday 23rd of July at 3:30-4:50. We will speak about how the Icelandic financial crisis simulated the origin of Obsessive Compulsive Problems. The discussion will be about general belief in magical thinking, such as the paranormal, horoscopes etc, and how these thinking patterns may influence people’s coping strategies. Venue: Estelar, Room: Arequipa

The next World Congress of CBT will be Melbourne, Australia in 2016, and Ross is a convenor. It is amazing how much work goes into planning these conferences. Even though it is still 3 years away, Ross has been busy planning the 2016 conference for a while now.

First up is the opening ceremony with Aaron Beck, the father of CBT!

 

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

I recently came across the webpage of a talented designer who has a few comics on social anxiety. Here is an example:

Social anxiety comic

(Click on the comic to see the original post.)

This comic is very insightful, and beautifully illustrates two points:

  • People without social anxiety often fall victim to the cognitive fallacy “something that is easy and natural for me should also be easy and natural for everyone else – all they need to do is try”. These are usually well-meaning individuals, but they couldn’t be more wrong.
  • Overcoming social anxiety is difficult. Like learning a language, it requires learning and practicing a new set of skills. This takes time and dedicated effort. In fact, overcoming social anxiety is much more difficult than acquiring most new skills, such as an instrument or a language. This is because it involves critically evaluating and challenging core thinking and behavior patterns, which operate at both emotional and cognitive levels.

Please let me know if you’ve seen any other social anxiety-inspired art.

In other news, I’m off to Lima, Peru in a few days for the The World Congress of Behavioral and Cognitive Therapies. I will be presenting data from several projects, including the latest AI-Therapy results. Stay tuned!

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

If you regularly read mental health or science blogs, you’ve probably seen some recent posts about the controversy over DSM 5. There is quite a bit of controversy about it, so in this blog I’m going to give an overview, and share some of my thoughts.

 

What is the DSM?

The “Diagnostic and Statistical Manual of Mental Disorders” (DSM) is a manual published by the American Psychiatric Association (APA) that defines mental disorders, and specifies the criteria for a clinical diagnosis. In other words, it is the commonly accepted authority for answering the question: does person X have the mental disorder Y?

The APA periodically publishes updated versions of the manual to reflect the latest research findings. The first version was published in 1952, and the 5th version (DSM 5) was published earlier this month. Since there is quite a bit of time between publications, it usually generates a lot of interest.

 

What is the controversy about?

Each version of the DSM introduces new disorders, and updates the criteria for existing ones. This leads to the following situations:

  1. Some previously “normal” conditions are now a diagnosed mental illness. There is some concern that this will lead to drugs being prescribed to people who don’t really need them. Furthermore, some feel that the latest version of the manual goes too far, over-diagnosing the general population. Some professionals estimate that up to 50% of people now fit the criteria for at least one mental disorder. At what point does a “disorder” become normal human behavior?
  2. Some people will lose their diagnosis. In some cases, this could lead to individuals losing access to healthcare benefits they have come to rely on.

In both cases, the people and their symptoms haven’t changed. The only change is that a manual has been published.

 

The tyranny of the discontinuous mind

I believe many of the problems are related to what Richard Dawkins calls the “tyranny of the discontinuous mind”. We seem to have a natural inclination towards putting things in discrete categories, even when no such categories exist in nature.

The goal of a diagnosis is two divide people into two groups: those who have a disorder, and those who don’t. However, most mental disorders exist on a spectrum, and there is no precise boundary that cleanly partitions people into these categories. Any attempts to define such a boundary will inevitably lead to disagreements, since some people will argue the criteria should be relaxed, and others will argue they should be stricter. This is an unavoidable consequence of information loss when applying a threshold to a spectrum.

This is not an easy problem to solve. There are practical reasons why it is useful to have formal criteria for a diagnosis. For example, how else would a healthcare insurance provider decide who is eligible to be covered for a treatment? Therefore, the DSM plays a vital role in mental health treatment.

The main lesson is that a clinical diagnosis is only part of the story. People with mild symptoms can benefit from therapy, even if they don’t fit the criteria as specified in the DSM. This has some implications for online treatment, which I’ll talk about in a future post.

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