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

There is a well known 2011 study that looks at the brains of London taxi drivers. The map of London is complex, and taxi drivers are required to memorize the complete layout and pass a difficult exam before being given their taxi license. The study found that the hippocampus region of the brain, which plays an important role in memory, actually grows (in a physical sense) while the prospective drivers are studying for the exam. This is an interesting result since it clearly shows that our actions can make real, measurable changes to our brains.

 

Can you change your brain with therapy?

In short, yes.

Some people view psychological treatments as “softer” than using medication, since drugs can directly target neurochemical aspects of the brain. However, this view is unjustified, since there is mounting evidence that therapy can make very real structural changes to the brain. A great example is CBT.

Cognitive behavior therapy (CBT) is an evidence-based approach to tackling mental health problems, such as anxiety or depression. CBT has been subject to countless clinical trials, and has even been shown to be more effective than medication in some long-term studies. CBT works by targeting the thoughts and behaviours that are maintaining the problem (more information about CBT, and how it can be administered online, can be found here). For example, consider someone who has social anxiety and would like to ask their boss for a raise or promotion. This would be extremely stressful situation for them, and they would likely put it off indefinitely. CBT treatment would examine the thoughts that are leading to this avoidance, and would challenge them through a series of exercises. In much the same way that physical exercise changes the body, these mental exercises can make changes to the structure of your brain!

 

How does CBT change the brain?

The fact that CBT changes the brain is not a particularly new result. However, neuroscience journals tend to announce findings with headlines like “The neurobiological role of the dorsolateral prefrontal cortex in…”. The details are complex, but the general idea is understandable in surprisingly basic terms.

The brain is divided into different regions or modules, each of which is specialized to perform a certain type of task. For example, the visual cortex is the region of the brain that processes the sensory input from the eyes. There are some brain structures that deal with emotions such as stress and fear, and collectively these are sometimes known as the “emotional brain”. These are very “old” areas of the brain, in the sense that we share them with our distant ancestors. When a socially anxious person is nervous when thinking about asking for a raise, it is the emotional brain that is becoming active.

There are higher order brain structures that deal with planning, logic and reasoning. These are sometimes known as the “logical brain”. These brain areas, such as the prefrontal cortex, are “newer” in the sense that they are much larger in primates than in other species. There are two key points:

  • The logical brain is able to override the emotional brain. For example, our socially anxious person can take a rational look at the situation, and realize that he or she is exaggerating the potential risks. He or she might come to the conclusion “the worst case scenario is that the boss says no – that’s not the end of the world!” This thought will help them calm down, and build the confidence to actually ask for the raise.
  • Every time the logical brain overrides the emotional brain, the logical brain “muscle” becomes stronger and stronger. In other words, through CBT training the brain actually reinforces the neural pathways, so it becomes easier and easier to deal with future stressful situations.

This is good news: by changing our thinking and behaviour using CBT, we are making positive, long term, hard coded changes to our brains!

 

 

softonline

 

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

 

When someone is angry, quite often our immediate reaction is to tell them to calm down. However, have you ever noticed that telling someone to calm down can actually make them angrier?

In this blog, I’m going to discuss the reasons why some people get angry, and share some strategies to help prevent future outbursts.

Many of us have been in this situation:

AI-therapy.com anger management

The anger stimulus could have been many different things: an upsetting email, Microsoft Word’s AutoCorrect feature, Manchester United losing a match you had a bet on, or pictures of an ex-partner on Facebook. Whatever it was, the ancient “fight” response has been activated and blood is pumping through your body. You find yourself in what seems like a uncontrollable rage. However, the belief that anger is uncontrollable in some situations is largely a myth!

One of the most common misconceptions about anger is that it is best to “let it all out”. This comes from the faulty reasoning that pressure builds up inside of us, and screaming, kicking and shouting is necessary to release it. The truth (according to the latest scientific findings) is that screaming, kicking, shouting or acting out in other ways only makes a person’s anger problem worse in the long term! I am now going to discuss one reason why many people get angry, and provide an effective way for dealing with some types of anger.

We all react differently to frustrating and difficult situations. Many of us burst out in anger. A lot of anger outbursts happen due to our internal rules being broken. These rules can be due to moral or ethical reasoning. For example, when you hear about someone being cruel to a child. This anger may be justified, and is therefore difficult to address. However, some of our “rules” are much less clear cut. These are rules that have been created (or learned from family, friends or colleagues) about how we feel the world SHOULD work.

Consider this example: a few weeks ago I was taking a bus from the airport, and the driver was being very rude to me and everyone else. I was little upset, and found myself thinking “the driver SHOULD be more helpful to me and the other passengers”. Another passenger was also upset by the driver’s behaviour, and got in a heated argument. It actually escalated to a point where they were both yelling at each other. Almost certainly, the driver was motivated by SHOULD statements of his own. For example, “everyone SHOULD sit down so I can catch up on my schedule!”. Both parties felt violated, but was it really worth the outbursts?

One of the ideas behind cognitive behaviour therapy (CBT) is to identify and challenge or modify unhelpful thinking patterns, including these SHOULD thoughts.

Let’s look at some more examples of should statements, and consider advantages and disadvantages of believing them:

 

 

Everyone should always treat me nicely

Benefit Cost
I will be happy when I am treated nicely. A major disadvantage of this ‘should’ is that it is unrealistic. It is a fact that some people are rude and inconsiderate. If I think that all people should treat me nicely, I will become infuriated every single time it doesn’t happen. I will experience anger and frustration regularly. This thought is actually making me upset.

Dropping a belief like this is not an easy task. We all have a sense of justice in our head, encoded by our internal rules. However, unfortunately the world isn’t always a fair place. For example, some people are too entitled, selfish or narcissistic to care about the impact they are having on other people. Therefore, it is inevitable that we will encounter people who do not treat us nicely. In fact, we should actually EXPECT it to happen from time to time. If something happens that we are expecting, we are a lot less likely to get angry because of it, and we can learn to think of better strategies to deal with it.

 

 

I should always say “yes” to requests from others

Benefit Cost
Immediately after I say “yes” to other people’s requests I feel relieved to get them off my back. I will probably be taken advantage of in my personal and professional relationships. I will end up doing lots of things that I really would prefer to avoid. I will end up feeling overburdened. I will end up bitter and resentful of the demands of others.

Once again, this example shows how an internal rule can end up causing unnecessary distress. On the surface it seems reasonable, but if interpreted too strictly, it can lead to anger. For example, it may lead you to expect everyone else to always say “yes” to you, and may cause distress when this turns out not to be so.

 

Incidentally, SHOULD statements, and a deeper discussion about their role in your mood, are the topic of Part 5 of the AI-Therapy treatment program. The program also identifies your specific SHOULD thoughts, and formulates a CBT intervention to target them.

Back to the original question regarding anger myths and facts: how can you prevent outbursts? In the short term, try not to allow yourself to “let it loose”, as this can lead to a pattern of learned behaviour that is only supporting the anger response. It is better to step back, and try to remove yourself from the situation until the anger wave has passed. Every time you successfully stop an outburst before it happens, the better you become at it. Practice, practice, practice.

In the long term, you should take a close look at your internal rules (i.e. your SHOULD statements). It is very likely that some of these are underpinning your anger. Once you have identified your SHOULDs, CBT can be used to target them.

The world isn’t always a fair place, and it never will be. We can do our best to make it a better place, but we can’t always control the actions of others. However, you can learn to control your reactions to perceived wrongs.

 

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

 

Social anxiety is a persistent and chronic mental health problem1. It is estimated that between 7%-12% of people experience social anxiety at some point in their life2. This means that it impacts from four to seven million people in Britain alone!

The problem of social anxiety can come in many forms, such as extreme shyness, or worry about negative evaluation by other people. It is often persistent throughout an individual’s lifetime, and therefore determining the age of onset can be a complicated matter3. Research data on childhood social anxiety is scarce4 , but several authors report that onset is typical in the mid-teens or early adulthood5.

The vast majority of people who struggle from social anxiety never seek any treatment.6 It is widely established that a social phobia diagnosis is frequently missed in primary care worldwide.7 The shame and embarrassment that lie at the heart of social phobia are highly likely to be contributors to this phenomenon. Indeed, the embarrassment is the primary reason why socially anxious individuals do not report their symptoms to their family doctor8. In a study of 9,282 individuals it was evident that those with the most severe social phobia were the least likely to receive treatment9.

Astonishingly, once the diagnosis has been made, it can take up to 17 years for treatment to be sought.

 

One solution is online CBT treatment for social anxiety

Given the above problems, there is a strong need to find and facilitate ways to make it easier for socially phobic individuals to seek and receive professional help10. One of the goals of AI-Therapy  is to address this problem. The core ideas were developed as part of my PhD research, but have now been extended to be an online self-help treatment for a wider audience. One goal behind this method of service is to reach those who would never make into a psychology clinic in the first place. Furthermore, it provides an option for those who, for one reason or another, are unable to see a psychologist on a regular basis. Finally, the anonymity of online therapy can be an advantage for some clients.

1) Yonker 2003
2) Furmark, 2002; Kessler et al., 2005; Ruscio et al., 2008
3) Rapee, Schniering, & Hudson, 2009.
4) Rapee et al., 2009
5) Antony & Rowa, 2008; Antony, Federici, & Stein, 2009; Hofmann et al., 2009
6) Beck & Clark, D. A., 2010.
7) Beck & Clark, D. A., 2010; Lampe, 2009.
8) Davidson, 2007
9) Ruscio et al., 2008.
10) Beck & Clark, D. A., 2010; Lampe, 2009.

 

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

 

The six decades of excitement over Artificial Intelligence

Fresh air blew over the field of artificial intelligence (AI) in the 1950s. The initial excitement and optimism of its founders is well described by the famous quote of Herbert Simon: “I believe that, in our time, computers will be able to do anything a man can do. I believe that computers already can read, think, learn, create” (Simon, 1965 p. xiii). Yet the task turned out to be much harder than early researchers anticipated. For example, it took another three decades (1997) for the first computer to outsmart the top human chess player (IBM, 2010). This was unexpected, as chess, with its rigid and well-defined rules, seemed like an easy target for computers to master. Even in this case, the victory in 1997 was primarily due to the use of massive supercomputers and the availability of raw computational power, rather than the successful mimicking of human strategy, game play, and intelligence. Despite initial optimism, understanding and reproducing true intelligence (in a human sense) continues to be well beyond the reach of modern AI.

Eliza was a computer program that was released in 1966, still in the early days of the AI movement. The program responded to its users questions and statements that they typed on a keyboard. In many cases the users were convinced that a real person was behind the scenes (Weizenbaum, 1966). However, Eliza was fully automated, and based its output on algorithms that parsed the user’s input and formulated responses based on a programmed model. The model was designed to imitate the style of an empathic therapist using the Rogerian approach (Rogers, 1951).

 

Artificial intelligence and clinical psychology

Eliza was the first use of automation to create the illusion of human-human clinical interaction through a human-computer interface. In general, little progress has been made towards algorithmic techniques that are useful for treating mental disorders. The original goal of Eliza was to demonstrate and advance AI technologies such as natural language processing and pattern matching. In contrast, the goal within the clinical psychology community should be the application of these techniques using evidence-based treatment strategies to tackle real world problems. The development of fully automated therapists that are indistinguishable from human therapists remains an unsolved problem, and will continue to be for the foreseeable future. However, there are techniques currently available in the psychology literature that are suitable for automation, when treating specific, well-defined conditions.

how it works AI-TherapyA “computer psychologist” has been developed for AI-Therapy that can identify specific problem areas that patients report, and design individualized formulations and tailored treatment components with corrective feedback. Importantly, the computer psychologists has variety of strategies in place to direct the user in such a way that errors made on behalf of the users are kept to a minimum. As an example, participants are not asked to tell the program what unhelpful thoughts they experience, but rather the program offers suggestions based on file audit data and the clinical experience of developers. In this way, the computer psychologist is able to propose tailored cognitive behavioural therapy (CBT) techniques, such as cognitive restructuring exercises, behavioural experiments, etc. Furthermore, sample answers were written for over 1000 of the possible situations that a client might encounter, allowing the “computer psychologist” to give automatic corrective feedback. The advantage of this is that this knowledge and experience can be made available around the globe and accessed by an unlimited number of people at the same time.

 

For more information about AI in clinical psychology:

Helgadottir, F. D., Menzies, R., Onslow, M., Packman, A. & O’Brian, S. (2009a). Online CBT I: Bridging the gap between Eliza and modern online CBT treatment packages. Behaviour Change, 26 (4), 245-253. Cambridge Journal  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

 

Nobody sat down and decided to create the Internet

In March 1989 the blueprint for the Internet were sent by  Tim Bernes-Lee to his boss at CERN. It had the humble title of: Information Management: A Proposal. The comment he got back was “Interesting, but vague”, but he was allowed to continue to pursue this Information Management System. It’s creation was motivated by Tim wanting to communicate with other researchers around the world. For this he created what we now know as the Internet.  It certainly is not exclusive to nerdy researchers anymore, more accurately it takes up most of our waking lives!proposal

The community needs better access to evidence based techniques

AI-Therapy.com came about in a bit similar manner. I was finishing my clinical psychology Internships in Sydney, Australia.  However, before my last year had finished I was awarded a prestigious PhD scholarship at the University of Sydney. There was a major dilemma, do I miss out of this exciting scholarship award which was funded to respond to the need for evidence based treatments using the internet, or do I not finish my clinical psychology training/internships?

From this AI-Therapy was born.

My solution to this problem was to generate a fully automated computer psychologist which could be treating people online simultaneously with me working at the various hospital settings for my internships. It turns out, that to solve my problem of doing two things at once, I created a product which helped bridge the gap between the need for access to evidence based psychology techniques in the general community. After many years of hard work, I am pleased to announce that this service is now available to the general public under the name of AI-Therapy overcome social anxiety. You can see how it works here.

If you are interested in the original research for this computer psychology service, please refer to the following research and the associated publications

 

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