cognitive behavioural therapy « The AI-Therapy Blog

There’s definitely, definitely, definitely no logic to human behavior
-BjÖrk

I tend to agree with Björk (my fellow Icelander) — especially when it comes to “common sense” approaches to self help for improving anxiety or mood issues.

Despite having about 1000 trials supporting the efficacy of cognitive behaviour therapy (CBT) in the long term, the average Jane or Joe still has not heard about CBT. CBT has consistently outperformed medication when you look at long term benefits. What you learn through the CBT sticks with you for life! First, it addresses the root of the anxiety by determining what is keeping it going in everyday life. Next, it tackles the underlying cause using experiments and exercises. With CBT you develop strategies that you can use for the rest of your life.

One of the most common ways for individuals to deal with symptoms of anxiety and depression is to purchase self help programs (books, e-books, CD/MP3s audio series, etc.). The quality of these programs varies widely. There are some very good programs out there written by experienced and qualified professionals. Some of the best programs walk the client through the principles behind CBT.

Unfortunately, for every high-quality program, there are many more poor quality programs created by “self-help gurus”. Sometimes these gurus are well meaning people who have managed to cure their own problems, and would sincerely like to help others. Other times they are created by people simply looking for a quick buck. The problem is that some techniques for dealing with mental health issues are counter-intuitive, so without proper training, self-help authors can actually make problems worse. Let’s look at an example.

A typical title for self help books might be: Successful small talk: Learn to be open, interesting and intelligent. The purpose is to advise individuals on how to better manage their impressions on other people in social situations. If only human behavior was that simple! It would be great if we could sit down and read a book that would transform us into interesting and intelligent super-humans. Unfortunately, many of the recommended strategies (e.g. rehearse what you say in advance, make constant eye contact, etc.) can actually maintain anxiety in the long run. I mentioned these processes in my last blog, and referred to them as safety behaviors.

For social anxiety, people often believe that their safety behaviors help prevent negative evaluation in social situations. However, they actually might be preventing them from learning the truth. For example, assume that I deal with my social anxiety by only telling people about the positive aspects of my life (like many of us do on Facebook!). Perhaps I believe that this will stop them from judging me negatively. The problem is that if I never test this hypothesis, I am never comfortable being myself. What is wrong with this?

Firstly, it is unrealistic. People are people, and everyone has their ups and downs. By putting this extra pressure on myself to always look perfect, I might start avoiding social situations, reinforcing the anxiety. Social situations become extremely stressful.

Secondly, this type of safety behavior might make people judge me negatively. For example, people may feel resentful about my “perpetually success”, or suspect that I’m not telling the whole truth. Also, this maintains my social anxiety in the long run since I can never test if people approve of me for who I really am!

On the surface, common sense advice like “people don’t want to hear about your problems — focus on the positive” sounds great. However, as we’ve just seen this isn’t the case. Unfortunately, many self-help books are full of these sorts of recommendations.

There are some great self help books or programs out there. My advice is that if you do follow a self-help program make sure that it is (1) is created by a qualified professional with training in psychology/psychiatry, (2) uses CBT to tackle the core problems, and (3) does not promote behaviors that might end up making the problem worse.

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,

What is therapy or psychotherapy?

I’m often asked by friends, family, and people I meet, “what is therapy or psychotherapy?” so I figured it would make a worthwhile topic for a blog.

Psychological therapy, or psychotherapy, is probably one of the more misunderstood concepts around. Its popularity is evident by the vast amount of coverage it gets in popular movies and TV. As a clinical psychologist, I often cringe when watching “therapy” scenes in pop culture. For example, I watched the last episode of the 6th season of Dexter last night, where the therapist proposes an untrue/untested/completely-bullocks theory about how Debra Morgan must be in love with her brother! Fun twist for a TV show, but this theory is horrible PR for the field of evidence based clinical psychology.

This example from Dexter provides a great illustration of why a good therapist needs to be a good scientist too. Why should someone called a “therapist” have the authority to tell people things that aren’t based on evidence? The expectation for professional standards for therapists should be no less than when you go to see your family doctor. You have the right to trust that your therapist is acting in your full interest, and acting in accordance with the latest scientific findings from clinical psychology research field. Sadly though, science isn’t trendy.

Back to the original question, what is therapy or psychotherapy?

The first few sessions of therapy involve answering many questions, and filling out some standardised assessment questionnaires. Next, the psychologist uses their clinical knowledge and experience to determine what is the problem. If it is anxiety, the therapists figures out what type of anxiety one is experiencing. There are many different types of anxiety. For example, anxiety can be social anxiety, generalised anxiety, obsessive-compulsive symptoms, panic symptoms or phobias for almost anything under the sun. Each of these diagnoses need a specialised and tailored individualised treatment. Therefore, it is highly individualised what type of treatment one can receive under the general umbrella of “anxiety” or “worry problems”. Once the therapist understands the problem and has prioritized what needs to be tackled, the actual therapy can commence.

Cognitive behaviour therapy (CBT) is the state-of-the-art therapy for many psychological problems. On average it takes 12-18 sessions, where a person meets with a therapist on a weekly basis. During this time, the therapist and the client work collaboratively on understanding the thoughts and behaviours that are contributing to everyday life problems.

This may sound straightforward, but it can be incredibly tricky to think about your own thinking, and understand your own behaviours, as well as the functions they serve. You learn to assess objectively what happens in every day life, and learn to tackle these using cognitive behaviour therapy strategies. In general, this leads to a more emotionally balanced lifestyle. The great thing about this type of therapy is that if it is done well, there are no side effects, and it continues to be effective in the long run. However, as opposed to many popular miracle cures popularised on TV and in movies, CBT takes work. However, as most people who receive the benefit from it will tell you, it is worth all the effort you put in.

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.

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.

A “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 …

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!

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