We just published an interview:  Hannah Boettcher on the mental health challenges that come with trying to have a big impact. You can click through for the audio, a full transcript, and related links. Below are the episode summary and some key excerpts.

Episode summary

In this episode of 80k After Hours, Luisa Rodriguez and Hannah Boettcher discuss 4 different kinds of therapy, and how to use them in practice — focusing specifically on people trying to have a big impact.

They cover:

• The effectiveness of therapy, and tips for finding a therapist
• Moral demandingness
• Internal family systems-style therapy
• Motivation and burnout
• Exposure therapy
• Grappling with world problems and x-risk
• Perfectionism and imposter syndrome
• And the risk of over-intellectualising

Who this episode is for:

• High-impact focused people who struggle with moral demandingness, perfectionism, or imposter syndrome
• People who feel anxious thinking about the end of the world
• 80,000 Hours Podcast hosts with the initials LR

Who this episode isn’t for:

• People who aren’t focused on having a big impact
• People who don’t struggle with any mental health issues
• Founders of Scientology with the initials LRH

Get this episode by subscribing to our podcast on the world’s most pressing problems and how to solve them: type ‘80,000 Hours’ into your podcasting app. Or read the transcript below.

Producer: Keiran Harris
Audio Engineering Lead: Ben Cordell
Technical editing: Dominic Armstrong
Content editing: Katy Moore, Luisa Rodriguez, and Keiran Harris
Transcriptions: Katy Moore

“Gershwin – Rhapsody in Blue, original 1924 version” by Jason Weinberger is licensed under creative commons

Highlights

What makes therapy more or less effective?

Hannah Boettcher: So broadly speaking, we have known for a long time, and it’s not controversial, that psychotherapy is efficacious and effective — so under control settings and less controlled settings. And in meta-analytic evidence, the effect size of psychotherapy is approximately 0.8 in comparison to no treatment — and that’s conventionally considered a large effect size. Another way to say this would be that in comparison to not getting therapy, getting therapy explains 14%ish of the outcomes in randomised controlled trials. 14% might not sound great, depending on what your priors are, but this is actually really good for healthcare: it’s on par with or better than effects of medications, both psychiatric and medically, and it’s superior to plenty of medical interventions that are considered effective.

Luisa Rodriguez: What do we know about how effective different types of therapy are? Are those compared in studies?

Hannah Boettcher: Yes, these are definitely compared head to head. And something that’s really interesting here is that specific treatment ingredients or therapeutic “modalities” are actually not strong predictors of better outcomes in psychotherapy.

Luisa Rodriguez: Right, this is a thing I’ve actually heard before, and it basically totally blew my mind. I don’t know where I got it, but I just really strongly had the impression that CBT, for example, was like a much more evidence-backed therapeutic approach than some others. So is it that any kind of therapy is just equally good, or is it that there are other things that explain variation in how helpful people find therapy?

Hannah Boettcher: Well, you’re definitely not alone in having that impression. Academic psychology and practicing clinicians don’t do a great job of communicating this idea that different modalities don’t predict better outcomes. And CBT is an example where there happens to be a tremendous literature on CBT being efficacious, but that’s not the same thing as saying that it’s better than all other modalities. So what’s going on here is that there are other factors that contribute more to outcome, basically, and they don’t seem tethered to exactly what modality is being done.

Luisa Rodriguez: Yeah. That’s wild. Can you say what those other factors are?

Hannah Boettcher: Yeah. Most of it is related to the therapeutic relationship. There’s the therapeutic alliance, which is like a sense of being collaborative and on the same team with your therapist. Empathy is huge here, a big predictor of outcome is the client perceiving their therapist as empathetic. Similarly, a sense of genuineness, trustworthiness, and engagement. And expectancy is really important too. So the client going in and thinking, “This has a chance of helping me,” and having a coherent story about how that might be the case.

Luisa Rodriguez: Right, OK. So it kind of sounds like: Do you like your therapist? Do you get on and trust them? Do they seem genuine and authentic to you? Do you feel like they care about you? And then do you think it could help you? Like, do you think it’s going to work?

Hannah Boettcher: And all of this cashes out in greater engagement and input and retention, where the client is sort of actively participating in their therapy.

Moral demandingness and slack

Hannah Boettcher: I think we have to acknowledge that we are under conditions where in fact there is not a fully satisfactory choice available: we’re in a universe where tradeoffs exist, we have finite resources, we have multiple things we care about, and we have incomplete information. So we have to make guesses and take risks — and that hurts. So I think self-compassion and acceptance come in here, like, “Damn, I so am wishing this were not the case, and by golly, it looks like it still is.” And then I think that it’s a matter of recognising that we aren’t going to score 100% on any unitary definition of “rightness.” And then recognise that, “Well, I could just look at that and stall out forever, or I could make some moves.” And probably making moves is preferable to stalling out.

Hannah Boettcher: This is a belief, actually, that I struggle with, that’s like: “If there is capacity left on the table, there has been a moral error.” I mean, it’s really quite a defensible position. The logic is like, “I do, in fact, wish to use resources for a purpose. Look, some unused ones: we should allocate them.”

Luisa Rodriguez: Yes. Concretely, I very much have this if it’s the end of a workday, and I have any more energy and I’m not totally spent, I could obviously do a bit more work. Or just money: like, if I have any savings, that feels wrong. And then what do we do?

Hannah Boettcher: Well, I think we have to get clear on two things that are true here alongside the very appealing philosophy proof. One is that following that rule positions you to be in a constant state of just barely OK, right? Like, every time you get a unit of mental health from the wellness factory and you’re like, “Immediately distribute to impact!” then you’re basically almost empty, or like a little bit in the red all of the time. And that’s just very risky and costly. It’s obviously painful, but it’s also going to put you at risk for burnout and for needing to take longer breaks to basically recover and care for yourself.

It’s also, in my view, needlessly painful as a matter of subjective wellbeing, to be in a constant insufficiency state. Every time you have a sense of ease, if you’re rehearsing, “There’s been a moral error,” this is just a terrible way to live as a matter of your own internal experience.

This is a hard one though. It feels so compelling. And the thing I remind myself of is that that feeling of compellingness is simply an incomplete description of what’s true. It does feel really compelling to use 100% of my capacity, and I do really feel that urge to allocate capacity whenever it shows up. But if and when I ever do this — which I do occasionally try versions of it — I end up feeling the effects, and it is not preferable. It’s almost like I have to tell myself, “You’re not well calibrated on this. You think that you want zero slack and ease, but you want an amount.”

Hannah Boettcher: So yeah, what’s the cost here? The cost is that I look at my calendar, and part of my mind is like, “You could do more. It kind of looks like you want to just have fun and chill.” And I kind of have to unhook from that thought, and just be like, “I see you. I see what you’re pointing at. You’re naming something that matters. And by the way, workability is also here.” So it’s an ongoing balance.

Self compassion

Luisa Rodriguez: I have to admit that I, for a long time, have just really bounced off the idea of self-compassion and off of compassion-focused therapy. It came up a number of times, and I kept being like, “No, I don’t want to do that.” My reaction to the idea of being more compassionate toward myself was like, that sounds like lowering my standards or letting myself off the hook or like some kind of over-the-top self-care that I don’t identify with. A little bit of like, “That sounds weak. I want to be strong.”

Hannah Boettcher: Yeah. That sounds like things I’ve heard inside my head and from clients before.

Luisa Rodriguez: OK, so it’s not just me. To some extent, I’ve made some progress on this. I don’t have those associations quite as strongly. But for listeners who do still have some of that, can you help us have a different framing?

Hannah Boettcher: Absolutely. The thing we’re aiming for is not “anything goes” or “my standards don’t matter.” The thing we’re aiming for is: No matter where I’ve set the standard, how can I show up for treating myself well and kindly and effectively along the way?

And let’s also be clear that self-compassion is actually useful. First of all, it’s justified. We’ve said this already: we are the sorts of creatures that suffer, and we suffer for reasons out of our control that we didn’t choose. In my view, that justifies compassion. But even separately from that, self-compassion works better than self-loathing and self-berating. When you’re in a constant state of self-criticism, this is kicking up additional suffering that you then have to metabolise. Whereas when you can relate as a matter of self-compassion, this actually enhances performance more than self-criticism does, and it makes for a better subjective experience.

Luisa Rodriguez: A better experience. Yeah, OK. That sounds totally right. Then I guess we’ve got to go all-in on self-compassion. Something more like: You are doing something super important, super brave, super valuable. Thank you for doing it.

Hannah Boettcher: Yes, yes. And you are materially creating a world where a lot of people are pushing toward impact, and that is worth being part of.

Why effective altruism can amplify imposter syndrome

Hannah Boettcher: I also think there are some cultural norms that are common in high-impact spaces that can amplify imposter syndrome a bit. So the sorts of questions that people are well-practiced asking about their projects — like: Where are the top problems? Which of these is neglected? How could we be doing better? If we’re doing things that aren’t a value add, we need to stop doing them — these sorts of questions that are useful for impact can easily start being applied to the self, where they pull for a deficit frame.

Then there’s also this sort of cultural norm or virtue around self-critique and humility. So if you’re complimented for your work, somebody in a high-impact space is probably going to be ready with an internal “Yeah, but…” Right? Because that’s a move that’s really well-practiced in these spaces.

Luisa Rodriguez: Totally. Just to dig in a bit more on a few of those things, some people are trying to do a lot of good, and some people are trying to do the most good they can — and in either case, maybe much more than is typical, we end up asking things like: Is what we’re doing good enough? Could we be doing more good? Do we have the right beliefs, or could we have the righter beliefs? Is this project that I’m working on going fine? How can I guess all the ways it could go wrong, so that it could go better?

And I guess it’s such an optimisation framing that ending up anywhere below optimal — which we don’t even know what optimal is, oftentimes, so it’s often pretty easy to tell a story where we are below optimal — then we’re setting ourselves up to feel inadequate, I guess.

Luisa Rodriguez: I think I both stand by the goal of trying to find ways to do better and to do more good. But how do you do that in a way that doesn’t also end up making you feel kind of chronically inadequate? Because you could always have done the project better or you could always be kind of reflecting more on your beliefs to make sure that you’ve got the right ideas about what the most pressing problems are or something.

Hannah Boettcher: I think we are aiming for a place where we can decouple the scorecard from our worthiness. So it’s of course the case that in trying to optimise the good, we will always be falling short, right? The question is how much, and in what ways are we not there yet? And if we then extrapolate that to how much and in what ways am I not enough, that’s where we run into trouble. And I think that we miss the fundamental difference between performance and worthiness, and that we want to keep that difference vivid.