Anxiety and worry « The AI-Therapy Blog

Last week was an interesting one, to say the least. It seems like there was non-stop stories about the havoc in the White House. One story didn’t get as much attention as the others (for obvious reasons), but it caught my eye because it made me think about cognitive behavior theory (CBT). I’m talking about Trump’s theory that the body works like a battery. He believes that people have a fixed amount of energy for their whole life, so we should avoid exercise and not overexert ourselves. To back up his theory, he points to all of his friends who exercise and need to get hip replacements and other medical procedures. Trump believes this theory, and he “feels” it is correct. Therefore, he decides to not exercise himself.

What does this have to do with CBT?

Post-event rumination is a central feature of social anxiety. This means that after a social event someone with social anxiety analyzes the interactions in detail to try figure out if they have done or said anything wrong. The problem with this approach is confirmation bias. If we try to uncover evidence for our “social errors” we will find it. This is not because something bad happened. Often we “feel” like we have said or done something that has upset someone. However, just because we feel or BELIEVE we have done this, it isn’t necessarily true. We are looking for supporting evidence after the fact, just like Trump and his exercise theory.

Evidence, evidence, evidence

What can we do to help make better decisions in life? One of the key ideas behind CBT is to become an evidence based thinker. For the exercise theory, a single google search would find scientific articles contradicting the theory. We don’t need to understand the importance of peer reviewed science to understand the many compelling arguments for cardio exercise, such as longevity, mental health etc. In some situations like this we need to trust our gut instincts less, and our brains more.

The same idea applies to looking at post-event rumination. Rumination can become a habit. One may believe it is a useful strategy to make sure they didn’t “slip up” in a given situation. However, this is not productive, and we need to work out a way to limit the time spent ruminating after social situations. We have to understand that most of the time we simply have no idea what another person is thinking. In other words, when we feel they are thinking poorly of us, this is usually without any direct evidence. It is just a product of our own minds, and is best ignored, just like Trumps theory on exercise!

Fjola Helgadottir, PhD is a registered psychologist at the Vancouver CBT Centre, who has previously worked in Australia and at the University of Oxford in the United Kingdom. She is AI-Therapy’s director and co-creator of AI-Therapy’s Overcome Social Anxiety. Twitter: @drfjola

More great news from AI-Therapy! There are currently several studies in progress designed to test how well the program works. The latest study, from the University of British Columbia, is showing impressive results, adding to the growing pile of evidence backing up the program. These preliminary results are based on students who participated in a randomized controlled trial. The work was led by Dr. Frances Chen and Dr. Chris Richardson, with Hugh McCall and Keith Patena running the day-to-day operations. Hugh will be presenting a poster on the preliminary results at two UBC research conferences (MURC & PURC).

The predecessor to AI-Therapy was created during my PhD from 2007-2011. For my thesis I designed and programmed (in PHP!) a program targeting social anxiety among those who stutter. After completing my studies I saw enormous potential for this field. I wanted to build state-of-the-art, evidence-based mental health treatment programs available to the everyone. Therefore, in August 2012 I launched AI-Therapy with the rebuilt “Overcome Social Anxiety” treatment program.

Since our launch in 2012 we have been growing organically, without external investment. The reduction in social anxiety symptoms we see among our users has been fantastic. For the statistical nerds out there, the effect size is 1.8, which is exceptional. However, user data is not a replacement for proper randomized control trials. Therefore, these latest results from UBC are an exciting validation of what we are seeing with our users.

These are exciting times for AI-Therapy, and the field of computerized therapy as a whole. I’ll leave you with some of the most recent testimonials from our users:

“Very informative and helpful program that I highly recommend for everyone suffering from social phobia. It encouraged me to really work on my disorder and I made huge progress! I’ve been going to a therapist and using medicine for quite a while but this I believe has been the most effective of all.”(Guðrún, 19, Iceland)
“Excellent resource, well worth it. I have tried many different CBT programs, workbooks, various therapists, and many different medications. AI-therapy has been the most effective of any of these!”(CM, 31, United States)
“Excellent course which shows deep understanding of the problems of social anxiety. I have learnt very much and would recommend this course. There are many strategies it recommends for dealing with this problem. It is written by experts in psychology. I have no hesitation in recommending this well structured course.”(Anonymous)
“Nothing else has ever helped me as much as this CBT program. I struggled with social anxiety for most of my life, and it has certainly held me back from experiencing life to its fullest. I began this program feeling very hopeless about my situation, thinking nothing could change my mindset and that my life would never be worth much. Now, I have the tools to fight the anxious thoughts and feel very confident about my future.” (Anonymous).

We all have stereotypes about people with social anxiety. A lot of people falsely believe that social anxiety is the same as being shy. However, this isn’t always the case. In fact, quite often I’m asked “How can I have social anxiety when I’m such a social person?” These are people who enjoy being the center of attention, and who have a constant stream of funny stories and interesting things to say. People like this can actually be the most socially anxious people in the room.

Here is the key to understanding this: people can have social anxiety about different things. Everyone is unique. For example, some people are very confident in job interviews and with regards to the performance at work, but are terrified at the thought of making small talk in the lunch room. On the other hand, some people are very chatty and sociable with their friends and colleagues, but experience debilitating anxiety when it comes to their work performance. Therefore, when clinicians are evaluating social anxiety, it is vital to understand the idiosyncratic differences between people, as these can have a profound impact on cognitive behavioral treatment.

The details vary from person to person, and can be complex, but social anxiety often forms through a process like this:

There is a particular incident in one’s life. e.g. in childhood
People read into these events, and make inferences about themselves. Normally, these inferences involve highly negative interpretations.
People take precautions to try to compensate for their perceived limitation of character.
In reality, the compensations are overcompensation, and over time these behaviours keep the anxiety going.

An example of an overcompensation strategy is “non-stop talking” (hence, the most bubbly person in the room). These people are uncomfortable with silence because they interpret it as “if I’m not participating in the conversation the other person might think I am boring”. It is important to keep in mind that it is not the behaviour itself that is the problem, but the motivation behind the behaviour. It is the WHY that is important. For example, non-stop talking between long lost friends is to be expected.

Other examples include:

always showing a lot of interest in other people’s lives (one of the recommendation in Dale Carnegie courses)
making excessive positive comments
asking a lot of questions
making sure everyone at a party is having a good time

Once again, these are not bad things in and of themselves. It is important to consider WHY you are doing these behaviors. If your motivation is related to how you want others to perceive you, you are probably doing it out of social anxiety

A core part of CBT treatment is to test hypotheses. For example, seeing what happens when you stop overcompensation strategies. It is likely that you find people will accept you for who you are. This is done on an experimental basis, and individuals need to see the point of these experimentation. It is easier said than done, which is probably why therapist have to truly understand the theories behind the strategies they are implementing.

This type of overcompensation strategies are known in the literature as safety behaviors or subtle avoidances. I have recently published journal articles on the topic, and I will be chairing a roundtable at the Anxiety and Depression Association of America ADAA conference in San Francisco on April 8th, 2017 titled: Harmful Safety Behavior or Helpful Coping Strategy? Understanding Client Behavior in the Face of Anxiety.

We are very pleased to announce our latest collaboration, which is with Dr. Frances Chen and Dr. Chris Richardson of the University of British Columbia (UBC). We will be evaluating AI-Therapy’s cognitive behavior program within the university’s undergraduate student population.

3 years ago I wrote about blog titled: “Is diagnosis necessary for online treatment?“. My answer was no. I believe that anyone can benefit from CBT strategies, whether or not they have an official diagnosis. CBT helps people make better choices in their day to day lives, often leading to an overall improvement in happiness and confidence.

The UBC trial will provide the online social anxiety program to people who have elevated scores on social anxiety, not necessarily a social anxiety diagnosis. We are excited to see the outcome of this research.

Can sauerkraut cure social anxiety? Yesterday an article was published in the Huffington Post with the title “Sauerkraut Could Be The Secret To Curing Social Anxiety“. The timing of this article is interesting, as only a few weeks ago John Bohannon conducted a fantastic experiment that demonstrates why you should be skeptical of health new stories. I highly recommend you read the full article. In brief, he conducted a bogus study that appears to demonstrate that eating chocolate helps people lose weight (wouldn’t that be great!?). Pretty soon his results were being reported by media outlets around the world. This exposed several weak links in the way scientific studies are conducted and distributed:

Statistics: There are many ways that statistics can lead a scientific study astray. One of the most common is a process known as data dredging, which involves testing a large number of hypotheses until one is found that appears to be statistically significant. However, effects found in this manner are usually due to random chance. Data dredging is often done unconsciously by scientists who are under pressure to publish results.
Effect size: Even when an effect is real, it is important to know how strong the effect is. In some cases it will be so weak that its impact is negligible.
Peer review: Peer review is one of the strongest tools we have to prevent the publication of poor quality work. However, even this system is flawed. As John Bohannon discovered in another expose, there are many so-called “academic journals” that claim to conduct peer review but will actually publish anything if a fee is paid.
Lack of fact checking: Often a journalist will lift a story directly from a press release without doing any background research about the publication or its authors.
Stories that sell: In order to increase sales, stories are usually given a “spin” to make them more exciting. This often involves catchy, but misleading, headlines, or twisting and oversimplifying the results.

All of these factors contribute to the poor state of health science reporting. It is not uncommon to see completely contradicty stories that are published within weeks of each other.

When you see a headline like “Sauerkraut Could Be The Secret To Curing Social Anxiety” you should resist the temptation to run to your local German deli and stock up on fermented cabbage. Rather, you should base your decisions on research that has stood the test of time, with multiple independent studies showing the same outcome. If you are serious about tackling social anxiety you should use a technique like cognitive behavior therapy (CBT), which has been demonstrated to be effective in hundreds of studies.

Fjola Helgadottir, PhD, CPsychol, is a clinical psychologist, who has worked in Australia and at the University of Oxford in the United Kingdom. She is AI-Therapy’s director and co-creator of AI-Therapy’s Overcome Social Anxiety program and the author of Flourish: Living happily while trying to conceive. Twitter: @drfjola