The Startup That Wants to Cure Social Anxiety
May 18, 2015 4:10 AM   Subscribe

Joyable’s website, full of affable sans serifs and cheery salmon rectangles, looks Pinterest-esque, at least in its design. Except its text didn’t discuss eye glasses or home decor but “evidence-based” methods shown to reduce social anxiety. I knew those phrases: “Evidence-based” is the watchword of cognitive behavioral therapy, or CBT, the treatment now considered most effective for certain anxiety disorders. Joyable dresses a psychologists’s pitch in a Bay Area startup’s clothes.
posted by ellieBOA (47 comments total) 25 users marked this as a favorite
 
How is CBT cheesy? What?
posted by b33j at 4:46 AM on May 18, 2015


ellieBOA: "Joyable’s website... looks Pinterest-esque,"
Unless you've actually seen Pinterest. I think he might actually mean it looks like something 'for women'.
posted by signal at 4:52 AM on May 18, 2015 [18 favorites]


"...But everyone has some anxiety and depression, and everyone could be a better version of themselves if they didn’t have those feelings,” he told me.

There is so much evil packed into that statement, that a simple internet comment cannot possibly do it justice by drawing all of its nastiness out.

What kind of business automaton is this that thinks there is a "better version" of oneself that is stripped of emotion?

Anxiety and depression can be painful, they can take over your life, the care and tending of them can cost you everything, but they are not, in and of themselves, bad things that must be pruned off so you can be shiny and new (and, judging from the tone of the article, better at your job, since that's the main reason you'd need a "better version," so you can get a promotion).

Our culture has no idea what to do with emotions that are painful. We turn shyness into social anxiety--a trait into a disorder--then force people to spend money in order to treat the disorder. We turn sadness into depression, fear into panic, every little thing that hurts must fit a diagnostic category, so that businesses can compete on the best solution to sell you. Except that now that your individual emotion has been turned into a disorder, it can be cured with a cookie-cutter therapy; CBT naturally lends itself to that mechanical approach, since it doesn't care about you, it is only concerned with its exercises. It is psychotherapy as bureaucracy.

(I am not opposed to CBT per se, just its dehumanized "do this checklist of why all your thoughts are irrational" version that insurance companies and now apparently startups want to jump on.)

For $99 a month, Joyable offers the equivalent of a self-help book and a call-center employee who is trained (how? for how long?) as a coach. For all the problems of therapy (and lord they are legion), at least a therapist has gone to school for this stuff.

What an ugly, ugly turn.
posted by mittens at 4:58 AM on May 18, 2015 [42 favorites]


Here's what I think about cognitive behavioral therapy, as it is often practiced:

Have you ever crossed your fingers for good luck? Made a wish before blowing out the candles on a birthday cake? Said "Bless you" after someone sneezed? Made a decision based on a "hunch" or "gut feeling"? Prayed to a deity or attended a religious service?

If you answered "yes" to any of these questions, you have no right to tell me that my thoughts are irrational.
posted by Faint of Butt at 5:07 AM on May 18, 2015 [4 favorites]


Have you ever ruined a romantic relationship because you crossed your fingers for good luck? Lost a job because you made a wish on birthday candles? Wanted to kill yourself because you said "bless you" after someone sneezed?

If you answered "no" to all these questions, you might reflect on the fact that practitioners of CBT are perfectly happy to leave some irrational thoughts and actions alone while targeting others.
posted by escabeche at 5:11 AM on May 18, 2015 [107 favorites]


I don't know. Social anxiety is pretty miserable for me, and I think it is pretty irrational. (I want to think that, because the only alternative is to think that I humiliate myself every time I open my mouth and many times when I don't.) It does impact my job, but it affects other aspects of my life even more. It prevents me from doing things I want to do and from enjoying things that I force myself to do. It keeps me home on weekends and up nights. It makes me boring and prevents me from meeting new people and making new friends. And when I finally got myself together and asked my doctor if I could see someone about it, the person I saw (a psychiatric nurse practitioner) immediately told me that I should take anti-anxiety meds and literally mocked me when I said I didn't want to do that right away. I'm not opposed to anti-anxiety meds: they've been a life-saver for various friends and family members at various times. But I'd really prefer not to start with that without trying other things first, especially since I'm on other drugs with which anti-anxiety meds can interact, and it was the only alternative I was offered. So yeah, if a start-up is going to give me an option that isn't "go directly to drugs," then I might be open to trying that, if there's real research that suggests that it might work.
posted by ArbitraryAndCapricious at 5:11 AM on May 18, 2015 [19 favorites]


I can't help but feel that it's going to end up like gyms--outwardly they're all about fitness, but the business model depends on people signing up and then not using the service. They advertise that you can contact your coach "as much as you like", but I'm guessing that especially with the coaches all in SF, it's only going to take a couple hours of their time every month to render a user unprofitable.

Nice idea, friendly fonts, but all the motivations point towards unprofitable at best and evil at worst.

That said, mittens, anxiety and depression are mental health conditions, not feelings. Feelings are feelings. You still have emotions after getting proper mental health care. Including negative ones. You just learn how to cope with them in ways that are healthy. If you don't like it, that's fine, but it's helped a lot of people. I just got my help from actual medical professionals, which is a long way from this. (I still struggle sometimes, but then, it's been awhile since I was seeing someone about it actively.) My anxiety disorder is not the same thing as "fear" or "worry", because I still have fears and worries when it's well-managed.

And, Faint of Butt, there's nothing wrong with irrational thinking until there is. It's got to be causing harm to be a thing that needs fixing. Again, if you feel fine, then great, you're fine. Not everybody is fine. I am entirely in favor of positive irrationality and silliness. Those things bear no resemblance to my panic attacks.

But this is not the fix I want.
posted by Sequence at 5:13 AM on May 18, 2015 [30 favorites]


I like my social anxiety. It limits my social interactions to only those I enjoy.
posted by Homemade Interossiter at 5:13 AM on May 18, 2015 [8 favorites]


My spouse has a clinical psych Ph.D. and is trained in CBT, so sorry if my last comment sounded touchy, that's where I'm coming from.

Also:

It assigns every client—the site never calls them patients

makes it sound like this is some weird Silicon Valley thing, but actually "client" is standard clinical usage.
posted by escabeche at 5:14 AM on May 18, 2015 [17 favorites]


He phrases it instead as “an issue of market segmentation.” In his home city of Chicago, he says, there are lots of therapists and it’s easy to find one. “But if I live in rural Iowa, it’s much harder to find a therapist if I need one.” Therapy-as-an-app could really help someone in a place with scant resources.

The founders and current team include:

- An MBA grad from Stanford
- Another MBA grad from Stanford
- A BA in Public Policy and Economics from Duke
- 3 guys with BSes in Software Engineering all from the Rochester Institute of Technology
- A designer with a BFA from Maryland
- A coach with a BA in English from Atlanta
- A coach with a BA in Human Biology from Stanford
- A coach with an MS in Marketing from Golden Gate University

Not a single credential remotely close to psychology in the lot of them, and considering their bios, I wonder whether any of these folks have done anything other than drive through Rural Iowa, let alone trying to understand the market segment of people who do not have access to a therapist for geographic reasons.

Come out and say it at least - this is an attempt to drive down the cost of seeing a therapist regularly, while simultaneously availing you of the inconvenience of all those appointments. People with limited income - who are most likely to not be getting treatment for a mental health issue - are not going to be able to afford $1,200 in out-of-pocket expenses for this service which isn't actually a therapist.

It is yet another MBA grad believing you can divorce actual educated knowledge in a subject from specialized training on the subject which allows you to employ BAs in English, Human Biology, and Marketing majors for pennies on the dollar of what an actual, trained professional costs. Beware.
posted by buoys in the hood at 5:19 AM on May 18, 2015 [51 favorites]


Thanks escabeche. There's harmless irrational thoughts that have next to no impact on me, but the powerful irrational thoughts can be deadly and I desperately want to be rid of those ones.
posted by NoiselessPenguin at 5:21 AM on May 18, 2015 [6 favorites]


Have you ever ruined a romantic relationship because you crossed your fingers for good luck? Lost a job because you made a wish on birthday candles? Wanted to kill yourself because you said "bless you" after someone sneezed?

No, but I've done all those things for other reasons. Just to be clear, I'm exceedingly familiar with anxiety and depression. I take lots of medication for them. I've adapted to the knowledge that despair and suicidal ideation form a core portion of my personality and lifestyle, and I'm comfortable with that. It's just the way I am, and nobody has the right to tell me that I'm "irrational" unless they're a paragon of rationality themselves. Anything less is hypocritical.
posted by Faint of Butt at 5:25 AM on May 18, 2015 [5 favorites]


It's just the way I am, and nobody has the right to tell me that I'm "irrational" unless they're a paragon of rationality themselves. Anything less is hypocritical.

I'm not sure that's how hypocrisy works. I can see that my best friend is being irrational about her body image while also knowing that I'm deeply irrational about my own. I can probably see it better for the personal experience. You can have the flu and be able to tell that your partner's sniffles are probably a bad sign. I'm not going to tell anybody they're bad, lazy, dumb, whatever for having depression or anxiety. But neither am I going to accept that someone who thinks the world is collapsing in on them is perceiving the situation with 100% accuracy. The core bit isn't "irrational" as a dismissal, it's "irrational" as in "your own thoughts are not guaranteed to be the objective truth of the universe".

Irrational is just the way I am, but I get much less caught up in it now than I used to, which gives me space to take meds and implement other coping strategies. If you're comfortable with where you are currently, then you don't need CBT or anything else. That doesn't make anybody who's benefited from it a hypocrite for acknowledging human fallibility while still being human.
posted by Sequence at 5:39 AM on May 18, 2015 [12 favorites]


Forget rational vs. irrational, then. Some people just plain do not like the experience of being anxious or depressed, and find that CBT can help them be less so. Presumably that is okay with you? If so... what is your argument with CBT, exactly?
posted by officer_fred at 5:39 AM on May 18, 2015 [7 favorites]


Human Biology can have a significant psychology component, and Stanford MBA usually taps a lot of psychology profs for the organizational behavior component, or have people with serious technically-not-psychology-we-just-use-all-their-methods-and-theories background. But nothing clinical, usually is done in an org behavior class, and they don't seem to have the clinical training, and both founders have economics backgrounds, which is the social science field that systematically pretends that psychology doesn't exist.

However, the statement made against the thing implies that clinicians doing psychotherapy systematically do know how and why psychotherapy works. This is not the case. The knowledge does not exist.

The fundamental critique to make against all methods of therapies is that inter-therapist variation is much greater than inter-method variation. That means that you might as well use psychoanalysis and go on about Oedipal bullcrap, just as long as you and the therapist believe in it. One of the great benefits of the clinical psychology literature over the cog psych stuff that I have to read is that even fairly technical debates are not incredibly hard to understand, with some vocabulary and statistics, and people actually know how to write. This may, however, feed this delusion. The Great Psychotherapy Debate goes on about all this.

There exists evidence for the training not mattering, which Wampold doesn't discuss, at least for group psychotherapies(abstract only, I'm afraid, until I can find a better study).
posted by curuinor at 5:41 AM on May 18, 2015 [4 favorites]


nobody has the right to tell me that I'm "irrational" unless they're a paragon of rationality themselves. Anything less is hypocritical.


I'm not sure what your experience with CBT has been, but mine was not about being told that I was "irrational", but rather about finding ways to better handle my particular flavor of irrationality in order to improve my overall life experience. The notion of hypocrisy never entered into it for me, because my irrationality was never presented to me as anything unique, or as any sort of personal failing; indeed, it was recognized as a more or less universal aspect of humanity, albeit one that is far more damaging to some than others.
posted by DiscountDeity at 5:47 AM on May 18, 2015 [10 favorites]


A good example of statistical skulldiggery: look at the buckets on the client age distribution chart in the Outcomes page. That's not the distribution of normative psychotherapy users, by far.
posted by curuinor at 5:47 AM on May 18, 2015


Also, my experience is that CBT practitioners are very into "therapy without therapists." The idea of "bibliotherapy" -- that is, how much help can we give people just by getting good self-help books into their hands? -- is of great interest and is widely studied. Here's one paper. So if anything, I think a psychologist's response to this might be less "This is a problem, it won't work to do therapy on the cheap without Ph.D. psychologists" but rather "This is a problem, people shouldn't spend $99 a month when they could just buy a copy of Feeling Good and do the worksheets."
posted by escabeche at 5:54 AM on May 18, 2015 [13 favorites]


Have you ever crossed your fingers for good luck? Made a wish before blowing out the candles on a birthday cake? Said "Bless you" after someone sneezed? Made a decision based on a "hunch" or "gut feeling"? Prayed to a deity or attended a religious service?

If you answered "no" to all these questions, you might reflect on the fact that practitioners of CBT are perfectly happy to leave some irrational thoughts and actions alone while targeting others.

When I did CBT with a really excellent therapist for pervasive anxiety, I eventually brought up some compulsive counting rituals I have. I always count steps on the way up and down, for instance, and I have this little game that involves counting syllables on my fingers to see if they are divisible by four. I explained these things to my therapist, and she said, "Does doing these things cause you any distress?" I said no. She asked me if doing them interfered in any way with my daily activities or living my life. I said no. She said, "Probably not worth the trouble to try to get rid of them, then." I said, "Oh. OK, then."
posted by not that girl at 6:23 AM on May 18, 2015 [24 favorites]


However, the statement made against the thing implies that clinicians doing psychotherapy systematically do know how and why psychotherapy works. This is not the case. The knowledge does not exist.

Who said anything about systematic knowledge? There is value in the accrued other knowledge that trained professionals acquire even if it is not a complete set.

One such reason is at least a fundamental understanding of where the knowledge base ends - my CB therapist told me flat out 'I don't think you need to keep seeing me. I don't have anything more to give you and you're managing fine on your own. Come and see me if anything changes.' And I stopped paying for her time.

Do you believe trained coaches in this arena with no body of practice to be held to, and representing a business model which requires a monthly subscription, will be as aware of the limitations of the practice? I don't.
posted by buoys in the hood at 6:23 AM on May 18, 2015 [3 favorites]


So if anything, I think a psychologist's response to this might be less "This is a problem, it won't work to do therapy on the cheap without Ph.D. psychologists" but rather "This is a problem, people shouldn't spend $99 a month when they could just buy a copy of Feeling Good and do the worksheets."

Yeah. I tend to agree with the up thread comment that the business model is Planet Fitness. It's the only thing that makes the coaches make sense in the context of the pricing. I dunno, is there really any large number of people who wouldn't do the work on their own but would find an e-coach sufficiently motivating?
posted by PMdixon at 6:24 AM on May 18, 2015 [2 favorites]


I'm intrigued that at least a portion of Metafilter is responding so negatively to what is essentially the Web X.0-ification of Metafilter's Favorite Books. I can see where this product could fill a niche in between the self-help book approach and full-on weekly therapy in terms of access, cost, and encouragement to "stick with the program". To make an analogy: for some people, buying a book on diet or exercise is the only investment they need to make lifestyle changes that enhance their well-being. Some people require the help of a weekly in-person consultation with a personal trainer or nutritionist to achieve positive results. And then there's the mass in the middle for whom something in between, such as joining a Zumba class or Weight Watchers, is the amount of investment and support needed to push the needle.

As the article notes, there have been many studies of online-based CBT programs and the effectiveness of the treatment modality is well supported. I'm more familiar with programs designed to address depression, but my understanding is that anxiety is even more amenable to improvement through CBT than depression, and I'm quite pleased to see this. Someone quite close to me has issues with social anxiety and I could see this being a useful product for them. When the idea of talking to a relative stranger provokes a strong anxiety reaction, it creates a significant hurdle to accessing individual therapy in and of itself.
posted by drlith at 6:25 AM on May 18, 2015 [9 favorites]


Sequence: "That said, mittens, anxiety and depression are mental health conditions, not feelings."

I have to disagree with this. The determination of what is and is not a mental health condition is a social determination, not a scientific one. It's a normative judgement, and our norms for "healthy" and "unhealthy" have been shifting with the increasing medicalization of feelings. If the feelings concerned here are a product of the more harmful/stressful aspects of the modern workplace (or school, social situation, etc.), if the "harmful" aspects of the feelings amount to no more than impeding one's ability to accommodate oneself to a toxic environment, then treating them as illnesses is a bad thing — we're depoliticizing and taking away the agency of individuals to critique their surroundings by blaming all problems on individual pathology and thinking.

[note: I've been diagnosed with both, myself, so please don't say I don't know what it's like. The "mental illnesses aren't feelings, they're medical problems" argument has made my life rather difficult. It's harder to fight for change outside myself once you've said the source of my problems is wholly personal.]
posted by Wemmick at 6:36 AM on May 18, 2015 [9 favorites]


drlith: " Web X.0-ification of Metafilter's Favorite Books"

Huh. I didn't know MeFi was so into self-help books. Kind of like walking into somebody's house and seeing the bookshelves full of, well, self-help books.
posted by signal at 6:38 AM on May 18, 2015 [2 favorites]


Huh. I didn't know MeFi was so into self-help books. Kind of like walking into somebody's house and seeing the bookshelves full of, well, self-help books.


You know that there's this question and answer/advice adjunct part of the site, right?
posted by PMdixon at 6:40 AM on May 18, 2015 [9 favorites]


Wow, the website design is so close to the random startup website generator (previously) that I'm honestly still not sure if Joyable is a real business or not.
posted by yeolcoatl at 6:55 AM on May 18, 2015 [4 favorites]


I think it's important to separate out the tone of criticism for how CBT is implemented/how it evolves and is perhaps co-opted, from any criticism of people who've actually had success from its use. It is good news when someone feels better, and if CBT is what worked for them, then that is really a good thing; the total weight of sorrow in the universe is a tiny bit lighter because of it.

In much the same way, I'm totally on board with how Wemmick above describes the "social determination" of what's a feeling and what's a condition--but at the same time, I would not claim that Sequence was wrong to draw things out that way. It's really tough to strike the right balance between what definitions personally work to make you feel better, and what definitions might work against the masses who do find their feelings hard to deal with, or hard to integrate with society's demands.

I am not a fan of CBT. I find its emphasis on thoughts-as-sentences limiting. I don't like the way it excludes both emotion and bodily sensation from analysis. I don't like the way it has been embraced as a cost-saving measure. I haaaaaaate filling out the stupid forms. But maybe I would've thought differently about it, had it worked for me. Maybe I'd be defending it here. After all, I have similar opinions about psych meds, after decades of trials and life-altering side-effects. Maybe what I think are political opinions about the way we construct mental illness, are really driven by my own failure as a patient.

But, maybe not. If I have trouble with tasks at work due to anxiety, where should I be locating the actual problem? Is it "Mittens is too anxious to do the job?" Is it "We should stop thinking of job descriptions as one-size-fits-all, and start thinking of a more decentralized model of tasks?" The first is certainly easier, as it doesn't require any organizational effort. It puts the burden on me to find the treatment that will make me a good employee. And if (as has happened through pretty much every job I've had) I eventually have to leave due to anxiety, the organization can find a replacement, without having to have questioned that insistence on the primacy-of-job-description.

So, for me--and not necessarily for anyone else, and my thoughts never call into question the validity of your history--for me, the idea that anxiety is a medical condition, an illness, rooted in irrational thinking, that can be cured by calling out that irrationality and categorizing it by error type, and more pertinently to the FPP, that that cure can be located in an app...well, it all seems too packed-with-assumptions for me.

(Now, make an app for mindfulness-based cognitive therapy, which I have found some success with, and we'll talk.)
posted by mittens at 7:12 AM on May 18, 2015 [9 favorites]


Wow, the website design is so close to the random startup website generator (previously) that I'm honestly still not sure if Joyable is a real business or not.

So the thing about that is that basically everyone in the world making a basic website for a product uses a framework that Twitter released for free called Bootstrap. It's the standard startup web design but a lot of other people are jumping on it too. And for good reason: the tools they give you are well-thought-out and convenient -- and it's all set up so that you don't have to do much to have your page look good on any device. But the layout is so standardized it's very easy to randomly generate parodies.

Anyway, I think in terms of helping turn mentally-ill tech nerds into people who function normally, probably more useful than this website (though of course less profitable, and more importantly less good for this guy's future VC resume) would be a rewrite/modernization of Feeling Good.

I think the 80s-ness of all the stories and, independent of that, the fact that the author is just a very corny guy, doesn't work for today's cynical youth. I mean, if that book was a person it would have a perm and huge shoulder pads.
posted by vogon_poet at 7:17 AM on May 18, 2015 [9 favorites]


CBT is not the only "evidence-based" psychotherapy. These days, even dynamic therapy can get its EBM on. But its more difficult to de-skill and scale this, so less start-up potential.
posted by meehawl at 7:22 AM on May 18, 2015 [3 favorites]


But, maybe not. If I have trouble with tasks at work due to anxiety, where should I be locating the actual problem? Is it "Mittens is too anxious to do the job?" Is it "We should stop thinking of job descriptions as one-size-fits-all, and start thinking of a more decentralized model of tasks?" The first is certainly easier, as it doesn't require any organizational effort. It puts the burden on me to find the treatment that will make me a good employee.
Ok, but this is not about my job. Social anxiety makes it difficult for me to interact with other people. I probably could find a job in which I didn't need to interact with other people very much, but I don't really want to live a life devoid of human interaction. I want to deal with this problem because it is a problem for me, in ways that can't be avoided without causing me to live a more-limited, less-fulfilling life. It's convenient for you to equate it with capitalist exploitation, but that's not how I experience it. I'm actually much better able to manage it at work than elsewhere.
posted by ArbitraryAndCapricious at 7:27 AM on May 18, 2015 [11 favorites]


So, it's ELIZA?
posted by Phssthpok at 7:51 AM on May 18, 2015 [1 favorite]


I am not a fan of CBT. I find its emphasis on thoughts-as-sentences limiting. I don't like the way it excludes both emotion and bodily sensation from analysis. I don't like the way it has been embraced as a cost-saving measure. I haaaaaaate filling out the stupid forms. But maybe I would've thought differently about it, had it worked for me. Maybe I'd be defending it here. After all, I have similar opinions about psych meds, after decades of trials and life-altering side-effects. Maybe what I think are political opinions about the way we construct mental illness, are really driven by my own failure as a patient.

I agree with you to an extent about CBT and especially it's use as a cost saving measure that can be used as a metric to somehow "measure" how well a mental health centre is doing. (Side rant - gutting of NHS mental health funding by the Tories - arrrgh)

But, I did find some of the exercises very useful for myself. Such as what was described to me as "Catch, Check and Change". In that you first "catch" the thought (for example, for me, that person smiling to themself is secretly laughing at me) then "check" that initial reaction against the more likely case that they just remembered something funny or they just got a funny text message and "change" your reaction based upon your updated understanding of the situation.

Even in the worse case scenario where they are laughing at me the "change" is to realise that that is not the end of the world and in the big picture really no big deal. Sorry, it's be a couple years since my last CBT session so I probably haven't phrased the quite right but I hope you get the idea.

The problem with that level of self-monitoring is that it can become all consuming and very draining and while it has made a big positive difference in my life it is more a band aid on a gaping wound sort of situation. I'm now in more tradition talk therapy which has been a revealation for me in getting in touch with my feelings again (fuck you SSRIs!) instead of tamping them down.

I think CBT can work well for treating the symptoms of, to stretch the metaphor, of someone with a mental small cut they keep picking at but with the help of CBT they can stop scratching and let it heal. But for the very damaged amongst us - which unfortunately includes me - I feel, at least for myself, that the hard work of engaging with your feelings and where they come from (childhood and all that jazz ;) is really needed together with CBT for full healing.

Sorry that got a bit long, rambly and self-centred - much like the inside of my head ;P
posted by Beware of the leopard at 7:51 AM on May 18, 2015 [1 favorite]


ArbitraryAndCapricious, I don't disagree with you. The original post did focus on workplace anxiety and so that was on my mind, but you're quite right. It's one thing for me to stamp my foot and demand that the business world change to accommodate the things I have trouble with; it's another for me to demand that the world in general tolerate my clumsy, terrified attempts at socializing, punctuated by the long breaks where I just can't handle it and fall off the map a while. I would much rather solve that problem than define it away.

Even there, though, I think I would rather jettison the medical model, which has not yet lost its historical shadows of the asylum. I don't want to define myself as sick any more than I want to define myself as crazy. Neither has led to particularly good results (except in terms of fellowship with people who have been through it, where language about this stuff can be a little freer). So I'm more interested these days in thinking in terms of mental habits and misplaced skills. I find this much more positive--to learn to put my attention on particular thoughts, feelings, bodily sensations, and make some room for them no matter how they might be labeled as pathological in other contexts--than to write them all down and say in what way they are in error.
posted by mittens at 7:57 AM on May 18, 2015 [2 favorites]


The thing is, I can't really think of ways that the world could change that would make this better for me. I don't think I'm sick or crazy, but I do think that I have thoughts that interfere with my ability to interact with other people the way that I would like to, and I would like to change that. I totally understand and value the social model of disability, but I can't figure out how to make it work for me in this instance. But I like the idea of thinking about mental habits and misplaced skills, although I'm personally ok with saying that some of my thoughts are in error.
posted by ArbitraryAndCapricious at 8:06 AM on May 18, 2015 [2 favorites]


Mental health professionals critical of this should take a hard look at themselves. By and large in the United States it's a pain in the ass to see a therapist. It usually requires missing work most of the time, paying out of pocket and filing paperwork for insurance reimbursement (or just paying completely out of pocket), calling to request an appointment far in advance and a whole host of other things that can seem like a giant insurmountable wall to a person with anxiety.

To contrast if I cut my hand while cooking or get a urinary tract infection, I can get treatment immediately and use my insurance card and fill out almost no paperwork.

If I have an anxiety attack I can call like twenty different people to figure out if they take my insurance and are accepting patients, try to get an appointment and end up with one so far out that by the time it comes around the condition has passed (though certainly not without harm). Guess I could go to the psych ER, but that's like shooting a squirrel with a machine gun.

I know this is not entirely the profession's fault, but it doesn't surprise me opportunists are getting on the fact it's so flawed just like Uber took advantage of bad taxi regulation that limited the number of taxis to a number far below demand.
posted by melissam at 8:36 AM on May 18, 2015 [17 favorites]


I know this is not entirely the profession's fault

It's not this, or any other health speciality's (dentists, surgeons, psych, etc.) fault that the U.S. employment standard prevents millions of people from getting a little time off to see a doctor for a health issue. It's also not their fault that the insurance industry is obstructionist towards people's care being made easy. If you talk to any health professional, both of these things make their jobs worse.

My wife and sisters are all pros, and they would love, LOVE, not to have to deal with insurance bullshit to take in someone who needs care.

I find it unnerving that the solution is not reforming the standards on the things that are actually causing the problems, but instead expecting thousands of specialists to work worse hours to compensate for bullshit employers under the spectre of being replaced by an unregulated app.
posted by buoys in the hood at 9:34 AM on May 18, 2015 [4 favorites]


melissam: "Mental health professionals critical of this should take a hard look at themselves. By and large in the United States it's a pain in the ass to see a therapist. It usually requires missing work most of the time, paying out of pocket and filing paperwork for insurance reimbursement (or just paying completely out of pocket), calling to request an appointment far in advance and a whole host of other things that can seem like a giant insurmountable wall to a person with anxiety.

To contrast if I cut my hand while cooking or get a urinary tract infection, I can get treatment immediately and use my insurance card and fill out almost no paperwork.

If I have an anxiety attack I can call like twenty different people to figure out if they take my insurance and are accepting patients, try to get an appointment and end up with one so far out that by the time it comes around the condition has passed (though certainly not without harm). Guess I could go to the psych ER, but that's like shooting a squirrel with a machine gun.

I know this is not entirely the profession's fault, but it doesn't surprise me opportunists are getting on the fact it's so flawed just like Uber took advantage of bad taxi regulation that limited the number of taxis to a number far below demand.
"

I have been really lucky between the ACA and a local organization called Heritage Behavioral Health. They take Medicaid with no co-pay. I have a counselor I see weekly, a case worker to help with some issues, and also they offer employment assistance with advocacy and wellness programs to boot. They even have an onsite pharmacy, even if I only get to see the psych every six months. It has been an amazing experience, and I wish they didn't suffer some of the funding crises they do.
posted by Samizdata at 9:38 AM on May 18, 2015 [2 favorites]


[note: I've been diagnosed with both, myself, so please don't say I don't know what it's like. The "mental illnesses aren't feelings, they're medical problems" argument has made my life rather difficult. It's harder to fight for change outside myself once you've said the source of my problems is wholly personal.]

Most people are not seeking mental health treatment as a result of having negative feelings from being in truly toxic environments. There are all kinds of ways that our overall social system is broken, but a healthy mind is capable of doing that whole "feel the fear and do it anyway" thing. Or the anger, or the sadness. If you feel that your emotions are a healthy response to being in an unhealthy place, then I respect your call on that! But I required therapy and medication to get to the point that I could go to events that I really wanted to be at with people I really liked.

A good friend of mine just got her dream job and got hit with crippling depression soon after, during what should have been the happiest time of her life. She's not having an existential crisis about the evil inherent in the system, which would be something else entirely. She's having the sort of problem that can very easily sideline a person who is passionate about social change and render them unable to think about anything further than bed. The thing about that "mental illnesses aren't feelings" thing is that feelings also aren't mental illnesses. If you don't need medical help, you're under no obligation to seek it. But you can't go around saying that everybody else is just being drugged or placated because they can't handle having feelings about things, just because things like this crop up that don't take such problems seriously.
posted by Sequence at 9:54 AM on May 18, 2015 [6 favorites]


Sequence: "[note: I've been diagnosed with both, myself, so please don't say I don't know what it's like. The "mental illnesses aren't feelings, they're medical problems" argument has made my life rather difficult. It's harder to fight for change outside myself once you've said the source of my problems is wholly personal.]

Most people are not seeking mental health treatment as a result of having negative feelings from being in truly toxic environments. There are all kinds of ways that our overall social system is broken, but a healthy mind is capable of doing that whole "feel the fear and do it anyway" thing. Or the anger, or the sadness. If you feel that your emotions are a healthy response to being in an unhealthy place, then I respect your call on that! But I required therapy and medication to get to the point that I could go to events that I really wanted to be at with people I really liked.

A good friend of mine just got her dream job and got hit with crippling depression soon after, during what should have been the happiest time of her life. She's not having an existential crisis about the evil inherent in the system, which would be something else entirely. She's having the sort of problem that can very easily sideline a person who is passionate about social change and render them unable to think about anything further than bed. The thing about that "mental illnesses aren't feelings" thing is that feelings also aren't mental illnesses. If you don't need medical help, you're under no obligation to seek it. But you can't go around saying that everybody else is just being drugged or placated because they can't handle having feelings about things, just because things like this crop up that don't take such problems seriously.
"

I, among other things, am diagnosed with major depression (along with ADD and possibly am on the spectrum), and it never fails to piss me off that people around me either tell me to cheer up or think I am being lazy.
posted by Samizdata at 10:12 AM on May 18, 2015 [5 favorites]


From the FPP: ""Joyable’s website... looks Pinterest-esque,""

I initially misread that as "Pinter-esque" and though hang on a minute; if there's one guy you don't want giving advice on how to avoid all those awkward long pauses caused by social anxiety ...
posted by Len at 10:20 AM on May 18, 2015 [6 favorites]


Our culture has no idea what to do with emotions that are painful. We turn shyness into social anxiety--a trait into a disorder--then force people to spend money in order to treat the disorder. We turn sadness into depression, fear into panic, every little thing that hurts must fit a diagnostic category, so that businesses can compete on the best solution to sell you.

I feel the need to trot this quote out again:
It's a poverty of the English language that we only have that one word, depression, that's used to describe how a little kid feels when it rains on the day of his baseball game, and it's also used to describe why people spend their lives in mental hospitals and end up killing themselves. But clinical depression really has to do with the feeling that you can't do anything, that everything is unbelievably difficult, that life is completely terrifying, and a feeling of this free-floating despair, which is overpowering and horrifying.
I'm not in therapy because I get nervous before a meeting. I'm in therapy because a very bad day includes sensory hallucinations. I'm not in therapy because I'm shy. I'm in therapy because I don't want to become my grandmother, whose paranoid lashing out nearly destroyed my family. I'm in therapy because I've come to the conclusion that the demon threatens kill me sooner or later.

Which is why the repeated equivocation between the kinds of emotion I wish I could experience without danger of escalation and the symptoms I try to control through therapy really get under my skin.
posted by CBrachyrhynchos at 10:51 AM on May 18, 2015 [12 favorites]


(Now, make an app for mindfulness-based cognitive therapy, which I have found some success with, and we'll talk.)

There's a mindfulness app called Headspace. Freemium.
posted by feckless fecal fear mongering at 11:47 AM on May 18, 2015


I have crippling social anxiety. My experience is probably not the same as others.

I hate framing things in terms of rational/irrational. It would be easier to deal with if it were, and something like CBT might be effective. For me, it is entirely and completely non-rational. It comes in at a raw physiological level, not at a cognitive level.

When I'm in a social situation (i.e., around one or more people who aren't me), the anxiety comes on in my body. I'm not at all thinking about other people's thoughts and perceptions, they are irrelevant.

This is not amenable to talk therapy, because there is nothing to talk about. There are no thoughts to explore. There's only physiology and behavior. The severity of symptoms varies like the weather, with no predictability. Here's a partial list of things that happen:

- avoid eye contact
- physical avoidance
- prosopagnosia (face blindness)
- shaking/tremors, especially of hands, but extending to whole body
- linguistic impairment
- elevated heart rate, respiration, and body temperature

These things occur with no cognitive element at all. I don't have to think anything about you to have this reaction to being near you. It even occurs when I am exclusively in the company of family and friends.

I am on my second type of medication for this. It doesn't seem to be helping very much at all. Heavy drinking alleviates the symptoms quite well, but that's not sustainable.

People who know me well are pretty much getting used to this, as just part of who I am these days. I have to explain to new people, particularly my customers, that my Parkinson's-like shaking and verbal stumblings are normal (I never shake when I'm alone).

These days I'm self-employed, and I really need to interact with people or my business will fail. Most of the time, I just power my way through things, accepting that panic is sometimes going to be my uninvited, embarassing companion that I have to apologize for. Some days I can't do it.

It really sucks.
posted by yesster at 12:37 PM on May 18, 2015 [12 favorites]


I've had patients referred to me with a diagnosis of "social anxiety". For some of them, it's pretty straightforward and a simple CBT-style intervention can produce rapid symptom relief and sometimes apparent remission. That's pretty gratifying in terms of rapid feedback to identify and treat. It suits some patients exquisitely well.

But there are others who arrive with the "social anxiety" diagnosis and turn out to have OCD, dissociation, PTSD, bipolar, psychoticism or frank psychosis. Some of them are uncomfortable being in crowds because they imagine people are sending them secret messages, or stealing their thoughts. Others are experiencing strong fantasies to strike at people, or to eat or to rape them. There can be a progression to somatic conversion that proceeds to seizure-like activity, or abnormal illness behavior. Good luck finding an app for that.

It's nice that they namecheck "PTSD" in the article, but kind of brush it off "their trauma needs to be addressed and treated before they can turn to their anxiety". There are so many kinds of trauma, and trauma-afflicted people, that this remark blithely elides over. It comes down to what someone mentioned up-thread, about 'all therapies being equivalent'. When you measure large samples, that's often true unless you drill down into some patient trait/state data), but what it's really saying is that as a class treaters (and the delivery systems they are embedded within) are not good at patient selection, at stratifying people into risk categories and high-probability responder buckets to particular strategies (*). And sometimes just saying "No" to prospective patients. Some individuals are much better at this than others and that's why it's important to find someone who knows the limits of their skillset with particular patients.

A website/app that takes all comers is going to have to work to create good patient selectors for optimal outcomes. The field itself has been struggling to find good outcome predictors (that's what a large part of the new NIMH strategy revolves around). I can't see any evidence that this group have the background or knowledge or patient data to make optimized treatment selection. "Social" and "Anxiety" covers such a wide gamut. And the statement that "everyone could be a better version of themselves" if they did not experience anxiety or depression is so wrong on so many levels.

* - In essence, this is what a large range of stratification and triage protocols do in surgery, cardiology, renal, pulmonology, critical care, etc. Bucketing patients into treat/not treat, and then further-bucketing the treat group into hierarchical classes of risk/benefit has been one of the major engines of reduced mortality and improved outcomes over the past 30 years.
posted by meehawl at 2:06 PM on May 18, 2015 [8 favorites]


This thing charges $99/month? Just buy an Albert Ellis or David Burns book, you'll be getting the best of CBT for 10 bucks.
posted by gehenna_lion at 5:19 PM on May 18, 2015


For a site that has in general been so quick to point out that "what works for one person doesn't work for another" when it comes to things like losing weight, I'm surprised to see such a different take on mental health here. I, for one, am glad that we have options outside of just pure medication - which, under the present health care system in the US, is likely to be the only covered treatment.

I am no stranger to medication, I think it's a good thing for me personally - It has changed my life for the better to such a drastic extent that I have a hard time articulating just how much of a difference it makes. I've also seen medications prescribed too quickly, or some that have done more harm than good. That doesn't mean that medication is inherently bad, it just wasn't good for those people.

Sometimes people are diagnosed incorrectly. That doesn't mean that the whole field is wrong.

Some people do use it as a crutch for modern life - but again, that doesn't mean that there aren't many others who are truly seeing a restoration of what they want to see as normal in their life. I see this accusation all the time with ADD/ADHD in particular.

If you are someone who has struggled with depression or something else that has a treatment option, but you managed to drag yourself out of it, I'm happy for you - but know that you are in the minority, and that doesn't work for everyone else.

For many others, medications or therapy provide the tools to drag themselves out of the pit they have been in. And for another subset, those are the only thing propping them up at all.

I have no experience with CBT, but I don't have a good reason to outright dismiss it either. I do think that we are awfully quick to rely on medication in the US - but look at the economic realities of treatment. If you have an insurance plan, it's likely to cover all of the psychiatric medications you could ever desire, yet not always pay for the management of said medication by a psychiatrist, and almost NEVER pay for an alternative form of therapy.

Lets look at depression for an example - If you are deep in it, it's probably a struggle to drag yourself to work every day and to keep bills paid. In this scenario, assuming you aren't one of the rare folk who can "will themselves out of it," what do you think the chances are of being able to pay for weekly sessions with a therapist are, and to have the time for those sessions with the demands of your job? This isn't even getting into how far out many therapists are booked... Looking at the options, $400 a month (minimum, I'd say) for just talk therapy starting two months from now but no meds vs. a $5-$50 co-payment with a Drs vist once every 2-6 months can seem like a no-brainer, especially if you have reached the point where you acknowledge that you want or need help.

If CBT is a viable option, and someone sees benefit from it, then by all means they should continue - and there is some value to be had with an interactive platform that can be done on ones own schedule, assuming that they are able to stick with it. I know if I was in the same financial place I was years ago, I'd be delighted to find a third option that wasn't on the more expensive end of the spectrum.

Finally -- "just read a book" is really unhelpful to people who have really truly struggled with their own problems, and have tried books with little result. A book is a great tool, but sometimes it isn't the right one, or it may not be the only one needed. I found great results pairing talk therapy with medication and books - Any one of those would not have anywhere near the same cumulative effect, and they all work off of each other very very well. Of course, it would be hypocritical for me to say that would be the case for everyone.
posted by MysticMCJ at 6:59 PM on May 18, 2015 [6 favorites]


" And when I finally got myself together and asked my doctor if I could see someone about it, the person I saw (a psychiatric nurse practitioner) immediately told me that I should take anti-anxiety meds and literally mocked me when I said I didn't want to do that right away. I'm not opposed to anti-anxiety meds: they've been a life-saver for various friends and family members at various times. But I'd really prefer not to start with that without trying other things first, especially since I'm on other drugs with which anti-anxiety meds can interact, and it was the only alternative I was offered."

Hear, hear. Taking pills properly gulped down has not worked for me, despite that FPP awhile back, and I get really tired of hearing that drugs are the first, last, and only option. If anyone's trying something else that might work, huzzah.
posted by jenfullmoon at 8:40 PM on May 18, 2015


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