Emma Watson did a wonderful speech for the UN recently, and if you haven’t seen it yet you should really check it out:

She launched a campaign called “HeForShe”, where men around the world are asked to join the gender equality agenda. The speech has gone viral (when I opened my Facebook this morning it seemed like half of my friends were raving about it). I came across some coverage of it with the headline “Her Voice Might Tremble, But Emma Watson’s Message Is Strong and Clear.” In my opinion, I found her voice to be very human and down to earth. I think her message was stronger because of this touch of tremble, which highlighted the fact that the speech wasn’t easy for her. Remember, this is a famous actress whose career is performing. She was nervous because nobody feels confident all of the time, and stepping outside of our comfort zone is when we grow.

This made me think of social anxiety and how we treat it. Cognitive behavior therapy (CBT) for social anxiety challenges people by moving them out of their comfort zones. We learn the most when we “put ourselves out there”. It is about experimenting with your thoughts and behaviors, and helping you live your life without fears.

I think a lot of social anxiety behavior in women is linked to gender equality. Sometimes we fear that by speaking our mind we will be labelled as “bossy”, whereas a man in the same situation could be called a “leader”. This is something we need to move past. For women, overcoming social anxiety can have a fantastic impact on their careers and self-confidence.

Fjola Helgadottir, PhD, CPsychol, is a clinical psychologist, who has trained all over the world. She 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.

I’ve just come back from the British Association for Behavioral and Cognitive Psychotherapies (BABCP) conference, which was held in Birmingham last week. The conference was excellent. One of my favorite talks was by my colleague Dr Clare Mein of Oxford University. She was presenting her PhD from the University of Western Australia, where she also trained as a clinical psychologist.

Dr Mein demonstrated in series of experiments how social anxiety can affect social situations. In particular, she found that people with social anxiety interact differently during conversations. For example, think about the last time you got lost in a conversation with someone who you are not anxious around (best friend, partner, etc). You got lost in the moment, and the conversation went smoothly. However, it’s very different when you feel socially anxious, isn’t it? When we are anxious there are many thoughts going through our head unrelated to the conversation itself. These are often related to impression management. Here is an example:

The research showed that these thoughts are one reason why people with social anxiety don’t get “lost in the moment”. Unfortunately, it also showed that the conversational partner typically notices this, making the overall experience worse for both people.

Dr Mein conducted an experiment with people who have low scores on social anxiety measures. She asked these participants to count the number of words starting with the letter ‘T’ while having a conversation. The results showed that the when the participants were distracted by the counting they weren’t fully engaged in the conversation. Furthermore, the conversation partners felt less connected. In the same way, people with social anxiety are often focused on something else (i.e. how they present themselves), having a negative impact on the conversation.

People with social anxiety often have a collection of impression management strategies that they’ve acquired over the years. One goal of treatment, such a with a therapist or an online programs like AI-Therapy, is to identify and let go of these behaviors. This frees you to focus on the conversation. The good news is that if you successfully overcome social anxiety you’ll be able to enjoy high quality social interactions with everyone, not just your friends and family.

Fjola Helgadottir, PhD, CPsychol, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy, a developer of online CBT treatment programs.

The relationship between salaries and social anxiety

It is a known fact that one area where social anxiety has a big impact on people’s lives is in the workplace. In particular, studies have found that people with social anxiety are less likely to be promoted and have, on average, lower salaries.

When was the last time you asked your boss for a raise?

Lack of assertiveness is one cause of this problem. For some people, being assertive is “too risky” since they have a strong fear of negative judgement – particularly by authority figures. For example, you might be worried about annoying or upsetting your boss, so you convince yourself that “now is not a good time to ask”. Unfortunately, the “right time” never seems to present itself.

In the past, psychologists and counselors would teach you techniques about how to present yourself. For example, common advice would be “make eye contact” and “stand tall with a straight back”. However, if you learn techniques like these without tackling the underlying social anxiety or the fear of negative evaluation, you’ll probably still struggle to gather the courage to ask for a raise.

Facing your fears (with CBT) can be a life changing experience.

One of the most effective ways to tackle anxiety is with a technique called cognitive behavior therapy (CBT). This is a long term solution, since it helps people evaluate and challenge their thoughts and behaviors, making them more likely to engage in activities they previously avoided.

In our AI-Therapy program, we use CBT to identify and target the thoughts and behaviors underlying the user’s social anxiety. Not only do our user report fewer social anxiety symptoms after completing the program, but also an increase in happiness and overall quality of life. Who knows – maybe it will give you the courage to ask for that promotion in 2014?

Fjola Helgadottir, PhD, CPsychol, 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 night I went to see Captain Phillips (not a blog-worthy experience in itself, but the movie was very good). One of the advertisements was for the latest Google Nexus 7:

This ad has been viewed millions of times on YouTube, not including all the views on TV and in movie theaters. The fear of public speaking has been a research topic within psychology for at least two decades, and major advancements have been made. In particular, it is now known that cognitive behavior therapy (CBT) is the most successful way to decrease fear and anxiety. Furthermore, the elimination of safety behaviors is a crucial component in tackling this problem. In this advert, it looks as if one simply needs to prepare (and being Google, “preparation” is watching YouTube speeches with a Nexus tablet). Obviously, there is much more to it than this. In fact, over-preparation is a behavior that can actually maintain social anxiety in the long term. In other words, sometimes the things we do to cope with short term anxiety are the very reason why the anxiety persists in the long run.

I am not saying it is unhelpful to watch clips of great speakers – we can all learn a lot from the masters. Also, being adequately prepared is important. However, real life can be more of a struggle than it is presented in commercials, and true gains are the result of hard work, not a fancy new tablet.

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

Quality of life is worse if you have social anxiety

Quality of life measures provide clinicians with information about their client’s “real life”. What do I mean by mean by “real life”? This includes topics like health, self-esteem, goals and values, money, work, hobbies, learning, creativity, love, friends, family, community, etc. People are asked to subjectively assess how satisfied they are with these various categories. Study after study has shown that living with an anxiety disorder can have a significant negative impact in all of these areas. It is important for effective therapy to consider the broader implications of a disorder, rather than focus purely on the specific symptoms.

The World Congress of CBT

At the 7th World Congress of CBT I attended a symposium called “Quality of Life and Anxiety Disorders”. The presenters included leading authorities in CBT, such as Lars-Göran Öst (Sweden), Lisa Liberman (Chile) Ron Rapee (Australia) and Thomas Ollendick (Virginia, USA). I was very impressed with the talks. Several of these researchers are investigating complex topics. As we all know, life is chaotic and complicated, and when we have a better understanding of the intricacies of anxiety disorders we will be be able to devise better treatments.

Quality of life and anxiety disorders at the 7th world congress of CBT: Discussant Thomas Ollendick

The cultural component of social anxiety

As a social anxiety researcher, one study that I found particularly interesting was conducted by Professor Öst of Stockholm University. He compared a group of social anxious individuals from the USA with a similar group from Sweden. He found that social anxiety interfered more with people’s real lives in America.

I asked Professor Öst to speculate on why he thought this might be the case. He hypothesized that it is likely cultural. Being an introvert is perhaps more consistent with Swedish culture. On the other hand, American culture may place a higher value on outgoing personality types. This is not to say that socially anxious individuals do not suffer in Sweden; it is simply saying that there is a cultural component to anxiety disorders that we should consider. Professor Rapee added that similar findings have been found in studies comparing Asian cultures with Western cultures.

The good news for Americans with social anxiety is that there are effective treatments, and these treatments are known to improve overall quality of life. Perhaps this why we are seeing such a strong interest from the US in seeking online treatment with AI-Therapy’s social anxiety program.

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:

Fjola presenting at the CBT world congress — 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:

USA
UK
Iceland
Australia
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!

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)

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.

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