Thanks for your reply, I hope I'm not wasting your time.
But appendix 2 also seems to imply that the evidence base for CBT is for it as an approach in its entirety. What we think that works in a CBT protocol for depression is different than what we think that works in a CBT protocol for panic disorder (or OCD, or ...). And there is data for which groups none of those protocols work.
In CBT that is mainly based on a functional analysis (or assumed processes), and that functional analysis would create the context in which specific things one would or wouldn't say. This also provides context to how you would define 'empathetic responses'.
(There is a paper from 1966 claiming that Rogers probably also used implicit functional analyses to 'decide' to what extent he would or wouldn't reinforce certain (mal)adaptive behaviors, just to show how old this discussion is. The bot might generate very interesting results to contribute to that discussion!)
Would you consider evidence that a specific diagnosis-aimed CBT protocol works better than a general CBT protocol for a specific group as relevant to the claim that there is evidence about which reactions (sentences) would or wouldn't work (for whom)?
So I just can't imagine revolutionizing the evidence base for psychological treatments using a 'uniform' approach (and thus without taking characteristics of the person into account), but maybe I don't get how diverse this bot is. I just interacted a bit with the test version, and it supported my hypothesis about it potentially being (a bit) harmful to certain groups of people. (*edit* you seem to anticipate on this but not encouraging re-use). But still great for most people!
Interesting idea, great to see such initiatives! My main attempt to contribute something is that I think I disagree about the way you seem to assume that this potentially would 'revolutionise the psychology evidence base'.
Questionable evidence base for underlying therapeutic approach
This bot has departed from many other mental health apps by not using CBT (CBT is commonly used in the mental health app space). Instead it’s based on the approach used by Samaritans. While Samaritans is well-established, the evidence base for the Samaritans approach is not strong, and substantially less strong than CBT. Part of my motivation was to improve the evidence base, and having seen the results thus far, I have more faith in the bot’s approach, although more work to strengthen the evidence base would be valuable
I'm not sure if it's helpful to think in terms of evidence base of an entire approach, instead of thinking diagnosis- or process-based. I mean, we do now a bit about what works for whom, and what doesn't. One potential risk is assuming that an approach can never be harmful, which it can.
The bot aims to achieve change in the user’s emotional state by letting the user express what’s on their mind
This is such a potential mechanism, it might be harmful for processes such as worrying or ruminating. If I understand the app correctly, I don't think I would advise it for my patients with generalized anxiety disorder, or with dependent personality traits.
Some therapeutic approaches (like CBT) are closer to being uniform (although, depending on how you implement them, sometimes CBT can be more or less uniform)
Others, like Rogerian or existential therapies, are highly non-uniform -- they don’t have a clear “playbook”
But a lot of Rogerian therapies would exclude quite some cases? Or there is at least a selection bias?
Sorry for my late response, Michael. I agree that being plugged into these networks helps, but I think academics (at least in psychology) are very open to this idea but lack the time (and maybe skills) to organize such an event. I think that if a local EA group (or student group) would approach some professors in psychology (or health economics) with the suggestion to organize an event about IAPT for the general public and policymakers in their name, a lot of these professors would love to support that. I bet we can find those professors in each country, and I am of course willing to help find them.
To broaden the analysis I think correcting for an implementation bias is useful. Fidelity to the protocol by psychotherapists is often way lower in real life than in research studies. This could make the average numbers more pessimistic, but the added value of a psychotherapist being aware of those cognitive impediments way higher, and possibly a more interesting career option (training and supervising younger therapists, lobbying for evidence based psychotherapy). But that just might be a self-serving bias speaking, the recent meta-analysis by Cuijpers made me doubt if I want to continue my work as a psychotherapist.
(2) The treatment gap between what works in research settings (efficacy) and what people really receive (effectiveness) is huge. Lobbying for initiatives like Improving Acces to Psychological Treatments in first world seems like a potential priority as well.
(3) About providing general psycho-education and media campagnes: I once saw an impressive talk by Jim White about Steps for Stress.
Maybe one sentence that can use some more context:
They also listed their most important needs during periods of crisis: Getting rid of voices and paranoia
There is nothing that you can do to help someone getting rid of their voices. On the contrary, encouraging them not to hear voices might make it worse. This is why Acceptance and Commitment Therapy is on the list of evidence based approaches. And why Validation of their experience; someone to listen who could be trusted is on that list of needs as well.
As with most psychopathology, trying not to experience stuff that often results in more of those experiences. Off course, do get help, and medication might help to get rid of voices. But changing how you cope with such experiences is also of use.
By the way, I e-mailed this before to CEA after attending the ABCT-conference in New York. ABCT= Association for Behavioral and Cognitive Therapies (US). Maybe interesting for some of you:
*Given the fact I heard a lot of ambitious attempts to reduce human suffering the last couple of days, I realized I haven’t encountered these voices in the EA movement yet.
Maybe these suggestions have been made before, but I’ll give it a try anyhow.
I make these suggestions as speakers, because I think none of these CBT-interventions are ready to compete with the most efficient ways of reducing human suffering. But still, I guess evidence-based talks on what human suffering is and how to reduce it, are still interesting for EA conferences.
1/ Steven Hayes
Stubborn bigshot in CBT, founder of Relational Frame Theory (RFT) & Acceptance and Commitment Therapy (ACT). https://en.wikipedia.org/wiki/Relational_frame_theory
Had an enormous impact on how CBT-therapists and researches view human pathology and suffering. He’s a fantastic speaker. And a nerd, I guess he’ll love EA and is able to make a great talk, for example on why human suffering differences from non-human-animals (language!), and what to do about it.
2/ Michelle Craske
President of ABCT. Presented this very ambitious project today: http://grandchallenges.ucla.edu/depression/
“Understanding, preventing and treating the world’s greatest health problem’
I think IAPT is the best way to go for systemic change on human psychological suffering right now. It probably has the biggest added value. Having those meta-organizations like NICE in the UK, the implementation of more mechanism-focused therapies and intervention for prevention will follow automatically.
Some random thoughts on psychology and EA. We need to make some distinctions.
On the one hand you have a theory about suffering. CBT doesn't have a clear fixed theory, it updates given the evidence. Most refer to these evolutions as first wave (behaviorism) vs second wave (revolution of cognitions, Beck, 'typical' CBT) and third wave (mindfulness-based (MBCT) & value-based (Acceptance and Commitment Therapy, ACT, a contextual behavioral science). The discussion continues.
Psychoanalytical and psychodynamisch therapies have different theories about suffering as well, but have some fixed ideas on the importance of early experiences.
There shoud be a difference between evidence based vs science based. Psycho-analytical (Freud, Lacan) theories aren't science based, although some interventions might be evidence based.
The dodo-bird effect is overrated and mostly people with different agenda's (promoting non science based interventions) misuse it to make their point. Be careful. Different forms of interventions do matter.
But psychology is a young science and a lot of things need to be fixed, updated and worked upon. Hope EA will contribute to this by taking a decent theory on psychological suffering into account. Before looking at evidence of different interventions. Contextual behavioral science might be a great place to start.
I was in contact with Michael before, and let me first say I'm happy he promotes the focus on IHI vs EHI in the EA community.
However, I disagree on how to think of IHI's. I've been struggling with how to think of human suffering since I learned about EA, and it seems to be caused by different views on human suffering between philosophers and what I've learned from clinical psychology, mainly by more pragmatic contextual behavioral sciences (not as an authority argument, but FYI I'm a clinical psychologist/CBT-therapist/PhD-student).
My argument boils down to these 2 points: 1) The premisse and constructs of the EA movement already causes a bias towards Positive Psychology and 2) there are better potential alternatives out there.
"Classical utilitarianism is understood as having three components. First, hedonism about well-being: what makes someone’s life go well(/badly) is experiencing happiness(/unhappiness) – as opposed to having one’s desires met or achieving items on an objective list – and every moment of experience has the same importance to their well-being. I’ll define ‘happiness’ here as any mental state that feels good to the person feeling it, and unhappiness as the converse."
So I believe this is a false distinction, and there is great added value in using a more pragmatic paradigm that can be considered as a third option. And that is: building contexts wherein people can live value-based lives, and preventing avoidable psychological suffering.
"(I note the distinction between mental illness and ordinary human unhappiness is arbitrary and nothing hangs on its precision: mental illnesses and ordinary human unhappiness are supposed to highlight different points on the happiness spectrum. I could alternatively have called these something like ‘clinical unhappiness’ and ‘non-clinical unhappiness’ instead.)"
Yes it is an arbitrary distinction, and contributes to the bias towards positive psychology. I don't see a reason why to make a distinction: humans are humans, and with the knowledge of how high prevalence rates of psychopathology are, it's more logic to assume that underlying mechanisms are present in each of us. The danger of making this distinction is that you end up with interventions targeting the 'ordinary human unhappiness' and not taking into account what these interventions do with people higher up the continuum of suffering. And that's exactly one of the criticism positive psychology receives.
This bias becomes more explicit in the article when Michael describes branches of psychotherapy.
"Regarding mental health a number of methods which have been shown to work including, but not limited to, Cognitive Behavioural Therapy (‘CBT’), mindfulness-based stress reduction (‘MBSR’) and, to a much lesser extent, Positive Psychotherapy. "
If it is to a much lesser extent, then why acknowledge Positive Psychotherapy? NICE guidelines (UK) and APA guidelines (US) don't regard positive psychology interventions as evidence based. (And by the way, classical CBT and MBCT can be regarded as just being part of the happy family of CBT). Another problem is the word 'methods'. Before we start thinking of methods, we need a theory on human suffering, so that when we think of interventions we don't just start from constructs like happiness. This discussion is very alive in the CBT-family, because of the rise of another branch: Acceptance and Commitment Therapy (ACT).
So EA'ers interested in this topic, please read on ACT and the underlying theory of it (Relational Frame Theory, RFT). Before we use numbers, we need a decent theory on suffering to frame them.
If this topic is still alive, I'll try to write another post on how effective altruism based on contextual behavioral sciences might look like. To say it very briefly, a distinction between two sorts of interventions is needed:
building contexts (by EHI) wherein each human being has the possibility to live towards their values (and that has the side effect of unavoidable suffering, e.i. by having the time to worry and grief about the loss of loved ones).
promoting contexts (by IHI) with the least possible psychological suffering.
Thanks for your reply, I hope I'm not wasting your time.
But appendix 2 also seems to imply that the evidence base for CBT is for it as an approach in its entirety. What we think that works in a CBT protocol for depression is different than what we think that works in a CBT protocol for panic disorder (or OCD, or ...). And there is data for which groups none of those protocols work.
In CBT that is mainly based on a functional analysis (or assumed processes), and that functional analysis would create the context in which specific things one would or wouldn't say. This also provides context to how you would define 'empathetic responses'.
(There is a paper from 1966 claiming that Rogers probably also used implicit functional analyses to 'decide' to what extent he would or wouldn't reinforce certain (mal)adaptive behaviors, just to show how old this discussion is. The bot might generate very interesting results to contribute to that discussion!)
Would you consider evidence that a specific diagnosis-aimed CBT protocol works better than a general CBT protocol for a specific group as relevant to the claim that there is evidence about which reactions (sentences) would or wouldn't work (for whom)?
So I just can't imagine revolutionizing the evidence base for psychological treatments using a 'uniform' approach (and thus without taking characteristics of the person into account), but maybe I don't get how diverse this bot is. I just interacted a bit with the test version, and it supported my hypothesis about it potentially being (a bit) harmful to certain groups of people. (*edit* you seem to anticipate on this but not encouraging re-use). But still great for most people!
Interesting idea, great to see such initiatives! My main attempt to contribute something is that I think I disagree about the way you seem to assume that this potentially would 'revolutionise the psychology evidence base'.
I'm not sure if it's helpful to think in terms of evidence base of an entire approach, instead of thinking diagnosis- or process-based. I mean, we do now a bit about what works for whom, and what doesn't. One potential risk is assuming that an approach can never be harmful, which it can.
This is such a potential mechanism, it might be harmful for processes such as worrying or ruminating. If I understand the app correctly, I don't think I would advise it for my patients with generalized anxiety disorder, or with dependent personality traits.
But a lot of Rogerian therapies would exclude quite some cases? Or there is at least a selection bias?
Sorry for my late response, Michael. I agree that being plugged into these networks helps, but I think academics (at least in psychology) are very open to this idea but lack the time (and maybe skills) to organize such an event. I think that if a local EA group (or student group) would approach some professors in psychology (or health economics) with the suggestion to organize an event about IAPT for the general public and policymakers in their name, a lot of these professors would love to support that. I bet we can find those professors in each country, and I am of course willing to help find them.
Great, thanks!
To broaden the analysis I think correcting for an implementation bias is useful. Fidelity to the protocol by psychotherapists is often way lower in real life than in research studies. This could make the average numbers more pessimistic, but the added value of a psychotherapist being aware of those cognitive impediments way higher, and possibly a more interesting career option (training and supervising younger therapists, lobbying for evidence based psychotherapy). But that just might be a self-serving bias speaking, the recent meta-analysis by Cuijpers made me doubt if I want to continue my work as a psychotherapist.
Great that mental health is getting more attention. Three random remarks that might be of interest:
(1) psychological treatments will probably evolve to become more transdiagnostic / process-based. For example Unified Protocol from Barlow, core principles in Acceptance and Commitment Therapy, the way the UCLA Depression Grand Challenge is taking shape, or the Research Domain Criteria. So most interventions described in this article are being dismantled which in combination with things like network analysis of symptoms (for example the things Eiko Fried is doing) should boost efficacy.
(2) The treatment gap between what works in research settings (efficacy) and what people really receive (effectiveness) is huge. Lobbying for initiatives like Improving Acces to Psychological Treatments in first world seems like a potential priority as well.
(3) About providing general psycho-education and media campagnes: I once saw an impressive talk by Jim White about Steps for Stress.
Great post. I'll try to make a useful contribution. Maybe this can be of help as well: the APA list of evidence based treatments:
Maybe one sentence that can use some more context:
There is nothing that you can do to help someone getting rid of their voices. On the contrary, encouraging them not to hear voices might make it worse. This is why Acceptance and Commitment Therapy is on the list of evidence based approaches. And why Validation of their experience; someone to listen who could be trusted is on that list of needs as well.
As with most psychopathology, trying not to experience stuff that often results in more of those experiences. Off course, do get help, and medication might help to get rid of voices. But changing how you cope with such experiences is also of use.
Eric Morris is one of the researchers on this topic http://drericmorris.com/ & this is a Twitter feed aimed at contextual behavioral science and psychosis https://twitter.com/ACBSPsychosis
By the way, I e-mailed this before to CEA after attending the ABCT-conference in New York. ABCT= Association for Behavioral and Cognitive Therapies (US). Maybe interesting for some of you:
*Given the fact I heard a lot of ambitious attempts to reduce human suffering the last couple of days, I realized I haven’t encountered these voices in the EA movement yet. Maybe these suggestions have been made before, but I’ll give it a try anyhow.
I make these suggestions as speakers, because I think none of these CBT-interventions are ready to compete with the most efficient ways of reducing human suffering. But still, I guess evidence-based talks on what human suffering is and how to reduce it, are still interesting for EA conferences.
1/ Steven Hayes Stubborn bigshot in CBT, founder of Relational Frame Theory (RFT) & Acceptance and Commitment Therapy (ACT). https://en.wikipedia.org/wiki/Relational_frame_theory Had an enormous impact on how CBT-therapists and researches view human pathology and suffering. He’s a fantastic speaker. And a nerd, I guess he’ll love EA and is able to make a great talk, for example on why human suffering differences from non-human-animals (language!), and what to do about it.
2/ Michelle Craske President of ABCT. Presented this very ambitious project today: http://grandchallenges.ucla.edu/depression/ “Understanding, preventing and treating the world’s greatest health problem’
3/ Vikram Patel https://www.ted.com/talks/vikram_patel_mental_health_for_all_by_involving_all?language=nl But apparently this link already exists a bit https://www.givingwhatwecan.org/post/2015/12/mental-health-interventions-may-be-more-cost-effective/
4/ David Clarke https://www.psy.ox.ac.uk/team/david-clark His work on IAPT is great: implementing evidence based care in UK to reach out to a lot of people. And changing the culture into one where data-collection is a great part of it. https://www.penguin.co.uk/books/184573/thrive/*
I think IAPT is the best way to go for systemic change on human psychological suffering right now. It probably has the biggest added value. Having those meta-organizations like NICE in the UK, the implementation of more mechanism-focused therapies and intervention for prevention will follow automatically.
Some random thoughts on psychology and EA. We need to make some distinctions.
On the one hand you have a theory about suffering. CBT doesn't have a clear fixed theory, it updates given the evidence. Most refer to these evolutions as first wave (behaviorism) vs second wave (revolution of cognitions, Beck, 'typical' CBT) and third wave (mindfulness-based (MBCT) & value-based (Acceptance and Commitment Therapy, ACT, a contextual behavioral science). The discussion continues.
Psychoanalytical and psychodynamisch therapies have different theories about suffering as well, but have some fixed ideas on the importance of early experiences.
There shoud be a difference between evidence based vs science based. Psycho-analytical (Freud, Lacan) theories aren't science based, although some interventions might be evidence based.
The dodo-bird effect is overrated and mostly people with different agenda's (promoting non science based interventions) misuse it to make their point. Be careful. Different forms of interventions do matter.
But psychology is a young science and a lot of things need to be fixed, updated and worked upon. Hope EA will contribute to this by taking a decent theory on psychological suffering into account. Before looking at evidence of different interventions. Contextual behavioral science might be a great place to start.
I was in contact with Michael before, and let me first say I'm happy he promotes the focus on IHI vs EHI in the EA community.
However, I disagree on how to think of IHI's. I've been struggling with how to think of human suffering since I learned about EA, and it seems to be caused by different views on human suffering between philosophers and what I've learned from clinical psychology, mainly by more pragmatic contextual behavioral sciences (not as an authority argument, but FYI I'm a clinical psychologist/CBT-therapist/PhD-student).
My argument boils down to these 2 points: 1) The premisse and constructs of the EA movement already causes a bias towards Positive Psychology and 2) there are better potential alternatives out there.
So I believe this is a false distinction, and there is great added value in using a more pragmatic paradigm that can be considered as a third option. And that is: building contexts wherein people can live value-based lives, and preventing avoidable psychological suffering.
Yes it is an arbitrary distinction, and contributes to the bias towards positive psychology. I don't see a reason why to make a distinction: humans are humans, and with the knowledge of how high prevalence rates of psychopathology are, it's more logic to assume that underlying mechanisms are present in each of us. The danger of making this distinction is that you end up with interventions targeting the 'ordinary human unhappiness' and not taking into account what these interventions do with people higher up the continuum of suffering. And that's exactly one of the criticism positive psychology receives.
This bias becomes more explicit in the article when Michael describes branches of psychotherapy.
If it is to a much lesser extent, then why acknowledge Positive Psychotherapy? NICE guidelines (UK) and APA guidelines (US) don't regard positive psychology interventions as evidence based. (And by the way, classical CBT and MBCT can be regarded as just being part of the happy family of CBT). Another problem is the word 'methods'. Before we start thinking of methods, we need a theory on human suffering, so that when we think of interventions we don't just start from constructs like happiness. This discussion is very alive in the CBT-family, because of the rise of another branch: Acceptance and Commitment Therapy (ACT).
So EA'ers interested in this topic, please read on ACT and the underlying theory of it (Relational Frame Theory, RFT). Before we use numbers, we need a decent theory on suffering to frame them.
If this topic is still alive, I'll try to write another post on how effective altruism based on contextual behavioral sciences might look like. To say it very briefly, a distinction between two sorts of interventions is needed: