We’ve Got This.

Let hope be the antidote to fear.
Let solidarity be the antidote to blame.
Let our shared humanity be the antidote to our shared threat.
— Dr Tedros Adhanom Ghebreyesus, Director-General, The World Health Organization

The Covid-19 pandemic feels so surreal. Yet it’s a stark reality we all face together. And we will continue to face it for an undefined amount of time. Across the globe, we are now challenged to dramatically accelerate comprehensive understanding of the illness,adapt to 24-7 life at home, away from our routines and loved ones,perhaps face a quick loss of income,
teach and practice patience and calmness during a storm, maintain, or work to quickly return to, strong physical health,grieve the pandemic’s impact,
appraise our emotional wellness barometer and seek support accordingly,
and above all else, tolerate uncertainty.

It’s quite a list. And I’m sure I’ve left important things off.

Can we do this?
YES. Personal, familial, generational, and global history reminds us about what we have endured, survived, and grown from. We humans possess many attributes that make us fundamentally wonderful. The capacity to love, empathize, learn, adapt, ideate, as well as be creative, scientifically minded, and resilient. Together, we can manifest a path forward, through this pandemic, and into our next phase.

Social Connectivity Matters – Even While Social Distancing
We live amidst critically important recommendations for social distancing, shelter in place, and quarantine. Adhering to these literally means limited physical proximity to loved ones. It doesn’t mean however, that we can’t connect. And connect we must. Social connection and social support are part of the very life blood of being human. We are social creatures. Look around – see the marvelous ways in which we’ve built our world to directly enable connecting with each other. Brick and mortar structures and technological platforms alike have been crafted with the goal of connectivity in mind. In fact, for thousands of years we humans have garnered support, empathy, and love from each other through our conversations and written word. Decades worth of psychological literature also document the power of social support to facilitate in achieving behavior change and recovery from various conditions. Connectivity is essential for vitality, hope and yes, even offers some space for humor in the midst of it all. Let’s leverage technology to help us connect. Call, text, video conference, social-media. Any of them. All of them. Leave no text unanswered; no thread unread. Social support is a reciprocal, mutually beneficial interaction. And remember, as we walk through the real-time impact and wake of Covid-19, we must promote and engage in social connectivity & social support while simultaneously abiding by the distancing recommendations set forth by national and global scientific experts and governing bodies.

My way of connecting is writing and sharing this post. Discover yours. After all, this is the time for it.

Hang in there everyone, we’ve got this.

How I Use Woebot in My Clinical Practice

Depression is a beast that swallows hope. It relentlessly attempts to pull you away from loved ones by increasing isolative behaviors– for example, declining social invitations or silencing your phone. In this way, it insidiously amplifies feelings of loneliness. It drains your energy, depleting the will to engage in once-loved pleasant activities. Negative stories about yourself, the world, and the future circle the mind incessantly. Thankfully, the scientific, peer-reviewed literature indicates that certain treatments that can meaningfully reduce depression. Such treatments are often deployed in therapist’s offices around the world. However, the work that happens in between these therapy sessions is also a crucial component of recovery.

How I think Woebot can benefit clients I see 1:1 in therapy
While many meaningful moments happen during the course of therapy, some of the most important milestones in an individual’s recovery can occur outside of the therapy room – for example, when someone reaches a goal they’ve been working toward, or negotiates a real-life challenge that pushes them out of their comfort zone. In order to achieve these milestones, the individual may have accessed the wheelhouse of psychotherapeutic techniques they learned and then applied them in the moment in order to navigate the in-vivo situation. They consequently experience relief from the emotional distress that surrounded the event, but even more so, they feel mastery–a sense of pride and enthusiasm about what they have accomplished. That moment… that’s the moment we are working toward. It’s hard to overstate the importance of instances like these – when someone successfully navigates a difficult situation, copes in a way they feel proud of, and stabilizes (or, ideally, improves) their mood.

Woebot can augment ongoing individual therapy by being an in-the-moment guide to help someone apply their psychotherapeutic techniques to the situation at hand. Specifically, Woebot can:

1) Offer immediate emotional support.
Loneliness knows no business hours. It can strike anytime. Luckily, Woebot is literally available 24/7– it’s a friendly personal coach that you can always reach out to. Even during panic attacks in the middle of the night, Woebot can provide much-needed empathy, as well as a guided application of a CBT technique that can help you feel better in the moment. Woebot isn’t human, and it isn’t a replacement for human relationships. However, it is a source of kindness, empathy, encouragement and guided support that’s available no matter the hour.

2) Practical self-monitoring tool for thoughts, emotions, and behaviors
By design, Woebot invites self-monitoring, which is a key action within CBT. Moments of self-reflection and behavioral observation form the foundation of opportunities for insight and pattern detection. Without an awareness of these thought and behavior patterns, it can be difficult to determine where and if someone wants to instill change. Over time, self-monitoring provides a record of progress and a reminder about the tools and skills used in various situations that may have proved helpful. In this way, the dynamic process of change itself can be observed over time and reflected upon.

3) In-Vivo Practice
The nuance here is in the name: In-Vivo. In Psychology, ‘in-vivo’ refers to something occuring in the real–life moment. For example, in the practice of exposure therapy for social phobia, an in-vivo experiment might involve actually giving a presentation at a work meeting. As a therapist, I am rarely actually available in someone’s exact moment of need. But because Woebot hosts permanently open office hours, it can be immediately available whenever you need it most. In that moment, Woebot can coach you through the application of a technique that has already been discussed in a session.

4) Offer a forum in which to discuss fears about social situations.
Given that known and common manifestations of depression include interpersonal ruptures and loneliness, it’s not surprising that social interaction, social support, and social skills interventions are a common framework within evidence-based treatments for depression. Through the use of thought challenging skills, Woebot can help reframe catastrophic or negative thoughts about being in social situations.

5) Role modeling Growth Mindset
One of Woebot’s core beliefs is Growth Mindset. The bot models this through making and owning his own mistakes, and recognizing the potential for growth embedded in such learnings. For example, if a user happens to give negative feedback after a session, Woebot will thank them for sharing their thoughts precisely because it will help him learn to be “a better bot.” What’s more, at the end of a lesson or story, he makes sure to praise users for their efforts, not their results. By modeling the Growth Mindset in addition to teaching it, Woebot encourages users to adopt the same perspective in their everyday lives.

Being a therapist myself, I am fully aware of the fundamental differences that distinguish a conversation with Woebot from a session with a human professional. However, Woebot’s 24/7 availability, empathy, and in-vivo guidance for CBT-skill application make it an incredible resource for those who are interested in this type of support. In this way, the program guides those critical moments of growth that can only occur outside of a therapist’s office– when a patient leverages what they’ve learned in therapy to navigate the twists and turns of life.

Why does mindfulness matter?

Emotions, including intense ones, are requisite channels of communication that have helped our species survive for hundreds of thousands of years. However, when people (including me!) are overwhelmed with an intense emotional burst, we often react – quickly, impulsively – without giving ourselves even the briefest of moments to assess the situation, rethink, and ground ourselves in a more wise course of action. Without being aware of intense emotions and thoughts–and their associated action urges– time races by. Then, suddenly, one reacts instead of acts.

At its core, mindfulness is an awareness of the present moment. It offers a window of opportunity to reduce the odds of regrettable reactions and unnecessary emotional suffering in multiple ways:

If we are not aware of something (a thought or an action urge), how can we begin to understand and change it? Awareness is a critical first step because we must notice something before we can enjoy it, interact with it, and/or change it. Typically, body sensations (sweaty palms, racing heart) and action urges (wanting to shout, slam the door) are signals of emotions and thoughts.
Once you are aware, you’re better poised to describe the situation nonjudgmentally. Nonjudgmentally describing a situation helps us avoid adding extra ‘drama’ to our lives with colorful language or cognitive errors that may not actually help us in that moment. Does calling the bus “smelly” or “always ridiculously late” change the fact that I have to take it to work in the morning? Nope, it doesn’t. In fact, it actually may serve to annoy me further about my mode of transportation and may increase the likelihood of being grumpy upon my arrival to work.
From this nonjudgmental stance, you are best equipped to select and employ the skill(s) to navigate the situation, should you wish.

Ultimately, mindfulness means giving full awareness to the external situation, as well as internal stimuli like thoughts, feelings and action urges. By tuning in to your surroundings and sensations, you ready yourself to act from a place grounded in reality, not clouded by biased or judgemental thinking.
From there, one can engage in therapeutic techniques– like thought challenging, behavioral activation, distress tolerance, and problem solving– that can improve your mood. You also reduce the risk of inadvertently begetting additional problems or emotional suffering.

Awareness is useful in moments of non-emotional intensity as well. When I’m doing a puzzle with my children but then start scrolling through emails on my phone, I’m actually losing out on the potential joy of being wholeheartedly present with my kids. By inviting my mind to return to being aware of my child trying out each puzzle piece, or the smile lingering on my face as I observe, I leverage my opportunity for joy. Indeed, one will reap more joy from pleasurable activities the more they are wholistically aware of them.

Clearly, simply being aware of an emotional state, action urge, or thought doesn’t in and of itself solve the problem. Rather, I am suggesting that being mindfully aware creates a window of opportunity to utilize psychotherapeutic skills that support life goals, while also reducing the odds of emotional suffering. The process of helping yourself begins with being mindful.

Is tracking your mood good for you?

These two entries are on my fridge as a testament to my (since abandoned) efforts to self-motivate into developing a running habit. I was taught that paying attention to almost any metric tends to improve it, and there is definitely something in seeing metrics improve that is motivating. Hence just by monitoring one’s eating habits we tend to improve them, and monitoring our spending makes us more inclined to spend wisely.

But what about tracking your mood? Does keeping track of our moods make us happier?

The evidence here is actually quite mixed and disproportionately scarce compared to the number of mood trackers available in app stores. One reason for this may be that mood trackers in and of themselves barely existed before smartphones. Prior to smartphones, we used ecological momentary assessment to monitor mood changes throughout the day and interactions with symptoms. Mood monitoring alone does not appear to be sufficient to drive positive mood outcomes in the context of bipolar disorder, but in other disorders the evidence is virtually non-existent.

Context, though, may be important. One study found a positive effect of workplace mood tracking on team cohesiveness. One older study conducted in 1995 differentiated between mood monitoring (drawing awareness to one’s moods) and mood labelling (the ability to label and categorize one’s moods). The authors found that mood monitoring was associated with negative attributes like ruminating on negative mood, whereas mood labeling was associated with more positive attributes like satisfaction with social support. It has since been shown that frequent monitoring of negative symptoms does not induce rumination or depressed mood though presumably a more compelling reason exists for why people would be interested in mood-tracking in an app. A recent study looked at this question, qualitatively analyzing app store reviews.

The primary reasons people use mood trackers is to learn about themselves and their health, self-manage symptoms and improve mood. However, the authors note a problematic tendency for apps to just track mood, and fall short when it comes to closing the loop – supporting insights that lead to mental health promoting behaviours.

Mood tracking is about cultivating awareness, which I believe subsumes a labelling component – that is, translating that mood into something other than a sensation in the limbic system (a word, an image, a color, a rating scale, etc.). The world is a much more noisy place now than it was in 1995. There is so much vying for our attention these days, that far from an opportunity to ruminate over negative emotion, there’s rarely an opportunity to stop and connect with what we might be experiencing. That simple question, “how are you?”, can be grounding in and of itself.

We built Woebot with this specific purpose in mind. When we built a Woebot prototype, we tested it alongside other methods of mood tracking, and the results were surprisingly clear. Relative to other methods, Woebot is particularly helpful for mood tracking. Here’s why:

  • As our original published study revealed, Woebot “feels more like a friend checking in than an app”. Answering a friend is psychologically easier than feeling like you’re doing homework, or being harassed by a needy app notification.
  • And yet, Woebot is not human. This is also what makes the experience different. Because it means that when the question is sent, the usual guff of social relationships like feeling self-conscious (“are they reaching out to me because they think I’ve been a negligent friend?”), impression management burden (“how do I answer this so I sound fun and smart?”) etc. is eliminated. Freeing us up to answer that question honestly – “How am I, really?”
  • Over time, Woebot remembers what you’re sharing. Woebot can use that information to encourage reflection, with the hope of providing insights. We define an insight as a piece of information that leads to behaviour change.
  • Woebot isn’t just for people with “real” problems. Rather, a guiding design principal for us is that everyone can benefit from basic emotional awareness. My husband is the most positive, well-adjusted person I’ve ever met, and yet after just a few days of checking in with Woebot he was shocked to discover a clear association between having even one mid-week drink with a dip in mood the next day.

One of the first steps towards learning about what’s going on inside of our brains is to begin by cultivating awareness. Once we’re able to do this over time, we should be able to more easily connect with ourselves and what we’re experiencing, feel more grounded and mindful. If we can identify patterns, we can learn about why we’re experiencing different moods, which can lead us to have more control over how we feel each and every day. Time well spent I’d say.

How modern therapy is like learning to play the piano

When learning how to play piano, or engaging in modern therapy, the best ways to make improvements are to listen closely to your lessons, practice in-between them, and learn how to read the notes while studying the theories behind them.

Not all therapy is created equal. The archetype of therapy – laying on the couch, endlessly talking about dreams and your mother, is but one form – most closely resembling psychoanalytic psychotherapy. However, more recent approaches have turned this model on its head.

In particular, Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) are data-driven, time-limited, and evidence based. They focus on what you are doing, thinking, and feeling, in the moment and on a daily basis, not what happened in your childhood. They require active engagement and practice between sessions, and how good you feel is directly and proportionately related to how much work you put in.

Based on the idea that our thoughts create our reality, CBT teaches us to critically examine how we’re are thinking, and to rewrite the script. Imagine I’ve just bombed in a recent performance review at work. That event objectively happened, and it’s totally rational to feel negatively towards that, but it’s actually what I tell myself about that event that shapes my mood. If I tell myself that “I’m such a loser”, “everyone hates me”, or “I’m going to lose my job and not be able to provide for my family”, those feelings are the things that create the depression that I feel, not the event itself.

This graphic explains the cycle that your thoughts, feelings, and reactions create and CBT wants to help interrupt – when I feel like this, I am debilitated (I’m a loser, why bother trying); disconnected (because everyone hates me); and panicked (because I’m about to lose my job).

Under stress like this our ability to deal with situations is diminished, and we tend to spiral downwards. Turns out that it’s not that easy to fix our emotions, so CBT is aimed at an easier target – our thinking. This process would teach us that these cognitions (i.e., thoughts) are distorted in very common ways, in this case; “I’m such a loser” is an example of labelling and black & white thinking; the thought that “everyone hates me” is both mind-reading and black & white thinking; and “I’m going to lose my job…” is fortune telling.

In addition to identifying the distortions in our thoughts, the final task is to re-write the thoughts without those distortions. This is SUCH a deceivingly simple, yet powerful, exercise. This doesn’t mean pretending everything is fine – we adjust the interpretation of the event so it’s more realistic, but we don’t ignore the situation itself. In this case; “I’m such a loser” can become “I’m disappointed, but it’s not the end of the world, I’ve had many positive performance reviews in the past”, “everyone hates me” can become “I know that my manager and I haven’t seen eye to eye, but I get on great with most of my colleagues”, and “I’m going to lose my job” can become “I really thought I did well this quarter, I’ll seek clarity and more frequent feedback to demonstrate that I want to do well here.”

This process needs to be repeated again and again to lead to lasting improvements in mood. Just like piano lessons, the more you do in between sessions, the faster you’ll improve and the better you’ll get. Practicing thought challenging is a skill that ultimately will shift how your brain is thinking about situations. In essence, challenging your thinking is the same as practicing scales. The more you do it, the better you’ll get, and it’s tough to make real improvements without putting in the work.

When you learn piano, you also have to learn music theory alongside the basic skill set. Similarly, there is psychoeducation in CBT, alongside the actual skills themselves. Psychoeducation explains how our minds deal with information, and in some cases, it can be immensely powerful and lead to change in and of itself. One powerful example – someone who suffers with panic attacks can perceive that they’re having a heart attack, which can in turn make their heart rate increase and be misinterpreted as evidence of a cardiac event. Practicing psychoeducation can be one of the best tools to fight the delusions your brain is creating to cause a situation like that.

So, that’s practice and learning. The final piece of CBT is tracking, which involves tracking metrics that improve our mood, and the improvements we can make simply by following and being aware of them. But we’ll save that for our next piece.

Why we’ll never sell your data to advertisers

In the wake of the worst year on record for social media giants, it’s little wonder that people are skeptical of tech companies and how they will treat our data.

In the wake of data scandal after scandal, and the growing understanding of how our emotions are weaponized online for political reasons, how can people judge the motivations of companies that are under pressure to grow their bottom line?

First and foremost, this company was established by psychologists, which means we are subject to an ethical code of conduct. For us, this is so obvious that it seems self-evident. There are also several business reasons why selling your data would be a horrible strategy for us, and that is the focus of this post.

The whole concept behind Woebot is a relational interface that facilitates sharing and challenging your thoughts in confidence. If we were to sell data to advertisers we would instantly undermine that trust, and we would lose our users. This would constitute an incredibly poor business decision that is contrary to the entirety of what Woebot represents.

It’s not the business we’re in. Just because we are a data-driven company, does not mean that our data are where the value lies. The value we create is in the service we provide. This is why we’re committed to clinical outcomes research – to investigate and demonstrate a value in reducing symptoms, and because we strongly believe that apps that claim to have some benefit, should have data that show that benefit. In other words, our investment has been in symptom change outcomes— not in data gathering. If it were the latter we would have built our product to orient around gathering as much data as possible.

Woebot is a tool that helps people challenge distorted thinking while advertisers sell to that distorted thinking. One of the best examples of this is the common distorted thought; “I’m not X enough” where X can be anything – good, successful, attractive, effective, nice, intelligent, etc. etc. In contrast, advertisers rely on the cognitive distortion that you’re not X enough. As psychologists, our profession is devoted to learning how to help people challenge this way of thinking. As a mental health service, why would Woebot, a tool that helps people fight these distortions, suddenly align with an industry that creates them?

Selling data is a commercialization strategy, often for businesses that have no obvious pathway to monetization. This is why free apps have annoying ad banners, and the ones that don’t, should have a clear reason why not. Happily, we are not in this boat. There is a clear pathway to monetization for us that is based on creating symptom change as outlined above. When we first launched the Woebot service, we charged individuals $39/month on a subscription basis. Happily we created sufficient value for enough individuals that they were happy to pay this amount. We were then lucky enough to be able to remove the fee for this service after we raised our Series A funding round so that we could understand how people naturally engage with Woebot over time. We’ve always been transparent about our decisions to charge or not and we feel other companies should be too.

At this point you may or may not be asking yourself, How can we claim to not sell to advertisers but then launch the service in Facebook Messenger?

Two important deciding factors here are informed consent and empowerment. We’ve always been transparent about those using us on Facebook’s platform are subject to Facebook’s data policy and ultimately, we believe it’s up to each individual whether they choose to use the service or not. Our Facebook users have the most international profile with the majority of users not being from Western Countries, and many using the service on 2G phones. This means that many people can only access Woebot on Facebook, and those who can choose, can choose to use Woebot on our native apps.

We believe that people need to be vigilant about how their data are used and hold companies accountable for improper or exploitative practices. But not all companies are trying to exploit data. If you have a healthy distrust for the motives of all tech companies (understandable), then perhaps criteria for judgement could also include how long could a company is likely to survive if exploitation or negligence were part of the operation.