Invent Health with Dr. Archana Dubey and Bambi Francisco Roizen; Episode 12Read more...
The new field of whole-person training and the evolution and history of behavioral sciences
Chief Product Officer of BetterUp Gabriella Kellerman sits down with Bambi Francisco Roizen for the VatorNews podcast.
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(Editor's note: On May 19 we will be hosting the Future of Mental and Behavioral Health 2021 virtual event. We'll have top-level VCs and C-level executives from the leading mental and behavioral companies, such as BetterUp, Teladoc's BetterHelp, Amwell, Doctor on Demand, Kaiser Permanente, Bessemer Ventures and more.
In 2021 it’s finally okay to talk about our mental health and that’s why we’re excited to be sponsored by BetterHelp. But what IS therapy? It’s whatever you want it to be. Maybe you’re feeling insecure in relationships or at work, or not very motivated right now. Whatever you need, it’s time to stop being ashamed of normal human struggles and start feeling better. Because you deserve to be happy. BetterHelp is a customized online therapy that offers video, phone, and even live chat sessions. Plus, it’s more affordable than in-person therapy but just as effective. See if it’s for you.
This podcast is sponsored by BetterHelp and VatorNews listeners get 10% off their first month at BetterHelp.com/Vator. This podcast is also brought by Octave, your partner for mental health and emotional well-being. Learn more at FindOctave.com. Also thanks to NeuroFlow which is working with hundreds of healthcare organizations to provide best-in-class technology and services for the effective integration of behavioral health. Learn more at neuroflow.com)
Here's the interview highly-edited for clarity.
Bambi 1:00: Tell us a bit about your journey from psychiatry to someone creating software products to deliver treatments or programs to boost our mental resilience.
Gabriella: I started my career in medicine. And I decided, as a teenager, I wanted to work on improving the emotional well being of our species of Homo sapiens. It's something that we haven't really moved the needle on in any meaningful way since we first appeared on this earth. We learned how to extend our life. We’ve improved our economic standing. But we’re actually not happier for it in an objective sense. That was my early vision and what drove me to a career in psychiatry. My career for the last 12 years has been in technology in building and leading products that combine human connection and software to drive change and better outcomes for the user.
Bambi (3:20): Given your last decade, it seems you’ve touched more people by working with innovative startups. You’re clearly innovating far faster than when you were in your clinical practice. For those unfamiliar with BetterUp, let’s talk about the company and what it does.
Gabriella: BetterUp is a global development platform. It includes personal coaching, and software-based tools to help people around the world work on personal and professional development. We primarily today work with fortune 1000 companies, and they'll give BetterUp as a benefit to some portion of their employees who then get access to a one-on-one coach and development platform to help guide their growth. People come to BetterUp to work on everything from burnout and stress management to becoming a more inclusive leader to rising in their career executive presence; They also work on leadership and presentation skills. Our coaches and our platform are there to support the entirety of what we call whole-person development.
Bambi (4:32): What percentage of employees engage with the service on average?
Gabriella: Almost all the employees who are offered it will use BetterUp at a given organization. It can be anywhere from you know, let's say a few 100 to several 1000 employees who are given access to the coaching.
Bambi: What are they primarily using it for?
Gabriella: It depends on the organization. There’s a few different types of use cases. One use case will be around helping support people in their career growth. So identifying people who are really promising but also wanting to give them more support. A lot of new manager type populations who are just becoming leaders. There's not a lot of on-the-job training for managers anymore, especially in a world where you can just suddenly show up one day, and you're leading a group. We’re also doing diversity and inclusion coaching. We're doing a lot to help leaders create more inclusive environments and help employees find ways of authentically connecting with others at work. This has been a big area of request recently. Then we coach around well-being so we do a lot of coaching to help people support their emotional health. That's been a huge need during COVID. We motivate people toward overall happiness and success in life.
Bambi (6:01): You started off with leadership training and coaching. With COVID, it seems like you had to zig and zag a bit to address emotions and resilience. Leadership is great because it’s aspirational to focus on how to become a great leader. With COVID, you had to also support those not trying to be leaders, but trying to get some baseline resilience.
Gabriella: That’s well said. It's also always been our mission to do all of that work. But I would say COVID really just changed the conversation and made it easier for us to be really upfront with the market about how important that emotional well-being work is to what we do. A lot of our buyers historically have not been interested in engaging with that part of our value proposition. They’ve focused on other talent outcomes. With COVID, we're finding that the people in organizations who really care about talent, and learning and development are working side by side now with the people who care about emotional well-being and emotional health. And that's a major shift in how that's been structured and how those conversations have gone. As of about five years ago, often those groups didn't really know each other that well or didn't collaborate together that well.
Bambi (8:50): Talk about the programs.
Gabriella: Most of our coaching is six months to a year. And occasionally we'll do something as short as four months of coaching. So you come in and you'll do a brief self assessment, that helps give us some insight on what we're seeing as your strengths and areas of opportunity and sets a baseline for measuring growth over time. We also allow you to select your own coach. From there, you’re meeting with the coach typically weekly or every other week. And in between sessions you're chatting or exchanging resources in sessions that are video or phone. We're measuring your progress over time as you go with both pulse assessments and then kind of longer check-ins.
Bambi (9:23): And how do you measure that? What's the baseline? And then what's the outcome?
Gabriella: We use our whole-person measurement. It's psychometrically validated, and it is there to provide what we think of as our periodic table of development. So there's so many things we each could work on, and we've tried to boil it down to these sort of atomic units of change. And then they kind of create these clusters across those depending on if you're working on, you know, relationships as an IC or building participation as a leader and sort of create these different clusters of skills that come off of that whole person model. And that also covers the full range of personal and professional. So again, the idea of the whole-person is our emotional well-being is deeply connected to our status and our functioning as leaders and as professionals. And it's all part of the same space. So capturing those connections is part of what it's designed to do as well.
Bambi (10:25): Is there a kind of a standard measurement? For mental disorders, there's the PHQ9 or Gad7. Is there a standard across the industry for well-being?
Gabriella: The industry or this area of science, we look to industrial organizational psychology, where there’s lots of scales, and I'll mention a few that are kind of standard there. There's positive psychology and, and in a lot of the wellness science, they use a lot of the same scales there. So some of the ones that people will think about are scales around employee engagement, which is a construct that's been really important and meaningful to corporate leadership for a long time. We don't necessarily think it's the most important, we actually use the concept of employee experience. We do measure the same things that employee engagement measures do. Part of the validation process with our whole person model is making sure that the scores on the things that we're measuring match up to those traditional scales. On the wellness side, there's some scales, like Diener Satisfaction with Life scale [read for more info]. It’s well respected. We ensure that there's high correlation with those measures as well. We have an amazing team of folks on our end and psychometricians who are making sure that we're, we're actually have high confidence for measuring the things we say we're measuring.
Bambi (12:47): Is how do companies pay for this? And what budget does this come out of it sounds like human resources.
Gabriella: Yeah, it's most often coming out of human resources and, and different parts of the human resources budget, depending on what the outcomes are that we're driving toward. And occasionally, it might come out of a line of business. So for example, you know, we'll do coaching with salesforce sales teams. And in those cases, it's like a chief revenue officer who is bringing in the coaching to help support their people.
Bambi: It seems like coaching is becoming such a want, I do want to ask you about your coaches, too, and how many people they can handle? But also how are they qualified? Because I'm sure there's such a boom in coaching. I'm sure there are a lot of kids who are going to school now thinking how can I be a coach? So from the coaching standpoint, what kind of degrees or qualifications do you need?
Gabriella: About half of our coaches are coming from a behavioral health background. And so we're looking for clinical degree in a certain number of hours in coaching, high-performing high-functioning individuals. So that that type of experience we find is really valuable for certain types of needs, like the emotional well being type of use cases that will do and the other half are coming from more of the executive coach training background. And there we're typically looking for, if you've ever heard of the International Coaching Federation, that's one body that is, you know, typically looked to as the certifying body and so there's like a certain level of degree of certification you can get from there that we're looking for, and hours of experience. It's not the same body in other parts of the world. So you know, we have coaches globally, and we've had to translate what that standard needs in other geographies. I will say, you know, over time, the vision is that we want to have as data-driven a view on coach quality and effectiveness as possible and you know, where we're quickly amassing the world’s greatest database on coaching outcomes. We hope expect plan that over time will be less dependent on external certifications in order to be able to say, you know, this person's excellent part of why we're so passionate about that. It's it's definitely coach quality, but it's also opening up the opportunity for more people to be able to become coaches, it happens to still be a very expensive path to go down. We want to have a greater diversity of folks who are in the coaching world, providing that service and have access to it as a career opportunity.
Bambi: Can they do so if they have a psychology undergrad degree?
Gabriella: No, that wouldn't be enough? It's a great start. But you do need that many, many hours of experience, either in coaching or in providing therapy.
Bambi: What percent of the healthcare budget is this?
Gabriella (16:30): I’ll start with the healthcare side, which is the benefits world, where we have our salary and compensation package. Most of what companies spend on under benefits is health insurance and other forms of insurance. Everything around wellness, and any behavioral health support is a pretty small number still today as a proportion of budget. Over on the other side of the house, though, the person who's focused on talent, and nurturing learning and development, has a different budget. And that budget is growing a lot. It's growing because the needs of the workforce to develop new skills is growing exponentially. That budget is growing in general. The other shift that's happening, which is what you're getting to, I think, is people are starting to understand that coaching doesn't just have to be for the top C suite level. Coaching now through companies like ours is much more affordable to many more in the organization. So that means that you can afford to actually spend more of that coaching across the workforce. And that's kind of the shift that we're seeing in proportion of that budget devoted to coaching.
Bambi: Another indicator is from the buyer side and the roles they’re creating. I’ve always had a Chief Happiness Officer. And I recently spoke with LinkedIn’s Chief Mindfulness Officer. Are you seeing the rise of these roles?
Gabriella: I think there’s a Chief Heart Officer someone introduced me to recently. For sure, I think it's all part of the emerging realization that our overall well-being is so deeply tied to our performance and our professional success. That is the realm of human resources. And something like mindfulness is a great example of a tool that's used both on the learning and development side and on the behavioral health side, but it gets split between the two. And really, it's the same tool; it's the same work to do; it's the same benefit. And so I totally can understand why they'd have a chief mindfulness officer there.
Bambi (19:35): Let's switch gears to product because that's what you're in charge of. What are some of the innovations you've worked on that have worked exceptionally well? What are some of the projects you’re working on today?
Gabriella: In the very early days of this work, I think just the idea of bringing together the virtual human connection with software around it was a very big kind of unlock. Is virtual care about recreating the care that happens in person or is it different? I think increasingly the work I get really excited about is, how do we make that human human connection even more impactful? How do we accelerate the progress through this virtual medium? Some of the examples of how you can get a lot more out of this medium than you can in an in person setting. A lot of traditional coaching and therapy might include activities that you would do skills or ratings or practices. When you're able to do those online, they can be adaptive. It's not a static piece of paper. They can change with you, they can grow and elevate the challenge Level. You can get a lot of feedback from the interaction with the computer that you can't get with a static kind of a worksheet. So that's one piece, I think there's a lot that we can also start to do with the data in and around the session itself. I'm really excited about that future direction of how we can gain more insight about who we are; how we interact with others; how we're growing in our ability to listen; how we're growing in our ability to ask questions, and thoughtful questions of others. That's some of the data you can start to get off of virtually mediated conversations. I've seen it be completely transformative for people to be able to get kind of objective data about how you're showing up and in relation to others through a virtual conversation.
Bambi: I can imagine you spending tons of time just thinking about how you can capture this data; You talk about the ability to listen better.
Gabriella: The way you'll capture that is through feedback surveys from others, or self ratings of what a good listener you are. But you're actually having all your meetings by video, so you can get objective data on how well you're listening through the video. In studying conversations, that's the kind of thing a lot of scientists are very excited about. Right now, a lot of social scientists have that ability to understand human interpersonal dynamics through video conversations.
Bambi: I’d imagine teachers and parents would want this via Zoom where teachers can give parents objective data showing their kids aren’t listening.
Gabriella: That’s a business there.
Bambi: What are the clues that somebody is not listening?
Gabriella: You can look at the balance ratio between how much I'm talking versus how much you're talking; you can look at how many questions I'm asking; you can look at pauses between a person’s speaking and me speaking versus me interrupting you. All of that is measurable and rich data to understand how respectful you're being of the way the other person is communicating.
Bambi (24:30): Let's go to the fun conversation around just sort of how all of this has evolved. So the therapy approaches used by BetterUp and many other companies are CBT and ACT, Acceptance and Commitment Therapy. These sciences are producing pretty effective treatments comparable to medication. What new information has emerged about our brain that helped us discover that we can influence our brain chemistry and anatomy?
Gabriella: CBT has been around for a while now. It's based on behavioral principles that date back to the early part of the 20th century. In some ways, it has the most robust evidence as an approach to therapy to change behavior. It's the bedrock of most forms of evidence-based therapy and there's things like ACT, which sort of grew out of CBT, in a way, and supplements CBT. ACT is kind of a values-based approach. And what CBT says is that there's a connection between our feelings, our thoughts and our behaviors. And we can take the time to slow things down and understand those connections; challenge some assumptions and challenge our biases and actually have greater clarity and grow to greater emotional regulation through that work. In terms of neuroscience, what's interesting is we've known for a long time that CBT is very, very effective. But we haven't necessarily been able to explain how those changes happen in the brain. And a huge breakthrough was in the 90s around neuroplasticity, and people like Michael Merzenich [learn more here] work were at the forefront of proving that the adult brain changes, basically. We didn't really even know that you could develop new neurons as an adult. We thought you had all your neurons when you were born or most of them. So the idea they were able to prove and discover that there's a lot of change in the brain that happens even once you're an adult, started to form the explanatory basis for what it means to use something like CBT to change. What we are able to see is that we're able through repeated practice rewire our brain. The effect of changing a habit, whether it's a thought habit, whether it's a thought association or behavioral habit, there's these centers of neurons that connect together across behaviors, thoughts and emotions that we're able to build new connections to new places and start to wind down through unlearning the connections that existed, and and merz and others really proved that that's possible. And that was always the theorized mechanism of how CBT happens. And they started to be able to actually show that that is, in fact, the case. You can see this happening also through fMRI. My background is in fMRI studies. And that shows you where there's brain activity. It doesn't necessarily show you that there's cellular change, but it shows you that certain centers of your brain could be active when you think about something and then you go through therapy, and they become no longer active. Through therapy, you’ve deactivated that locus of activity by figuring out that you can focus on something else.
Bambi: You're saying you can see this through the capturing of the MRI.
Gabriella: Through functional MRIs which show you real-time metabolic byproducts of brain activity.
Bambi: You said that it wasn't just the brain chemistry. The happy hormones, like serotonin, used in psychotropics or antidepressants. Those change the brain chemistry. But you said that the brain is already changing the cellular structure and anatomy. Briefly, what is changing there.
Gabriella (29:00): Neurons are the cells that form the connective tissue where we process information and send information. So we can see we can develop new cells. If you think of a neuron like an octopus with tentacles, we can change what those tentacles connect to based on learning and practice. When we get so good at something, we have so many tentacles connected to each other like an information superhighway with things moving quickly. We’ve been able to show how anatomical development takes place.
Gabriella: It helps us understand our own thought processes and make sense in a way that helps us move forward.
Bambi: Okay, so just to put it simply, the CBT view of stress and depression is really caused by the belief system or some sort of irrational belief system, to put it in some simple terms.
Gabriella (30:00): What it does is it helps us really understand our own thought processes; examine them; challenge them where they're inaccurate. And makes sense of them in a way that helps us move forward more aligned with the way we want to live our life on it.
Bambi: What is ACT?
Gabriella: Acceptance, a Commitment Therapy and and it's related in the sense that we're looking carefully at our thoughts. We're trying to bring in the lens of what are our deepest values and use that lens to help motivate us to recast, reevaluate decisions we're making and interpretations of events.
Bambi: So how is this view of treating unhealthy behaviors different from traditional psychoanalysis started by the modern, the father of modern psychoanalysis like Freud?
Gabriella: When Freud was coming up in the world, there were lots of people who actually thought more in behavioral terms as well. So it wasn't that he predated all of this. They're kind of two traditions that have existed in parallel, and grown and matured in parallel. In the early 20th century, maybe like 1920s, 1930s, psychoanalysis started to fall out of fashion because the scientific paradigm was really winning out and psychoanalysis never embraced the sort of empirical approach in the same way that the behavioral tradition was and. Really coming out of World War Two, there were a number of big wins on the scientific, empirical side, including, like some of the first psycho pharmaceuticals. Lithium discovered in like the 40s 50s, that were able to change behavior through old chemicals. And some, there were some animal models that started to prove very effective and predicting and understanding behavior. So all of those wins started to take over. And a lot of the energy and the funding in the field went into this much more scientific evidence based approach. Psychoanalysis still existed, and there's still plenty of people who are trained in it and learn it. But it's not like you're gonna find a big, you know, academic department of psychoanalysis today. They’re not going to get funding because it it's not for the most part, it's not evidence based. At the same time, there has always been people are really passionate about and interested in what psychoanalysis does best, which is really understand and think about the individual's experience of consciousness. And this tick, narrative case history approach to understanding what it means to be a human being. That tradition is always kind of come in and out of the scientific approach. When in the 1960s, Abraham Maslow and Carl Rogers and others started to try to bring it back they describe what they were doing is the third way of right so it wasn't psychoanalysis it wasn't behaviorism and this like highly empirical, they were trying to merge the two in humanistic psychology. A lot of the principles of humanistic psychology were the foundation for what we see in Positive Psychology Today, what we see in in the approach to evidence-based well being, but interestingly, humanistic psychology took off like wildfire with the counterculture of the 1960s. And it just became this like, big hippie thing. So even though that Maslow had himself, the desire to make it a science, most of the people in the movement did not and it became more of a cultural phenomenon rather than a scientific phenomenon. It probably just slowed it down in terms of maturing as a science and sideline data bit from a scientific standpoint.
Bambi: It sounds like positive psychology has its roots in humanistic psychology to CBT as well, because CBT is similar to positive psychology, or it is positive psychology, or what's the difference?
Gabriella: I would say humanistic psychology, the principles are very similar and the desire and what you know, what we're trying to get to, are very similar to fields like positive psychology. The how is different. So positive psychology is, you know, an empirical approach is evidence based, it's firmly within the scientific tradition. Or, you know, that's the intent of it. And, humanistic psychology never squarely established itself that way. And so that's actually CBT, I don’t know how Maslow felt about CBT back in that day. There was an anti-scientific element to humanistic psychology. Scientific establishment was viewed with suspicion.
Bambi: The science community also looked at CBT, and maybe positive psychology, to some extent, even five and 10 years ago, and questionioned its efficacy, right?
Gabriella: It'll be a constant, a constant battle. I think it's important also, just to make sure people know that it's not like this is only about positive psychology. It's about behavioral economics; it's about some of the latest positive neuroscience. How do we take everything we know from the broad behavioral sciences to help people grow and change? But these sciences will always be somewhat victim to these sorts of critiques. It's part of why I think a lot of the leaders in the field go overboard on methodology and overboard on rigor. I think it's part of making sure that it's clear that they are within that fold,
Bambi (36:33): Talk about behavioral economics, cognitive bias, interventions, like gratitude journals, and savoring.
Gabriella: We have now the benefit of, I would say, a good 20, if not 30 years of studies and evidence to help us understand what are interventions that help people live a good life and gratitude journal is one that you know. A number of important scholars have studied in all kinds of different formats and show that taking time to express gratitude is an important part of how we improve our well-being or optimism or outlook on life. Savoring is another mechanism of just really understanding; enjoying the good things that happen to you on any given day. Something we do in our family, we talk about the highlights of our day at dinner every night. And building in that ability to counter our bias to focus on negativity. We evolved to have a little bit of a negativity focus to avoid danger. But it's not actually in the interest of our overall well-being to get overly focused on the negative that we neglect the positive. So taking time to correct some of those biases in favor of your own positive outlook and ultimately, your physical and mental well-being.
Bambi (37:51): What is behavioral economics?
Gabriella: It’s an important, fascinating field of study that looks at how humans behave within the economic system, and it started to challenge the notions of classical economics, which didn't really take into account human behavior. By bringing the ideas of human behavior into economics, they're able to explain all kinds of dynamics in the market that didn't make sense through the lens of classical economics alone. So some of the things that the early behavioral economists Danny Kahneman and Amos Tversky were able to discover are these cognitive biases, a different type of cognitive bias than CBT examines, although there's tons of overlap between the two. These are ways of interpreting the world that don't rationally make sense, but have something to do with how our brains are built and wired. An example of a bias might be what they call recency bias. That's a behavioral classic, where information we gained recently, we're going to value over information that we picked up a while ago. This is because we have access to it more readily and it’s easier to recover. From a rational standpoint, it doesn't actually make sense. Because why should something I learned yesterday be more important or more valuable than something I learned a week ago?
Bambi: You could have fresh data that helped you come to that conclusion. I want to talk to you about the orientation of our entire healthcare infrastructure, the way it's oriented today, which is around sick care. Esther Dyson talked to me about this for many, many years, maybe about five years ago and when she started her program Welville. There's a couple of problems with our orientation. One, we're oriented to seek out sickness. Hence, at least in my opinion, this broadening classification of what is mental illness such as what is in the DSM, the bible for mental disorders keeps expanding. There is the “hoarding” disorder, which is described as having persistent difficulty discarding possessions. The fact that this is in the DSM, allows a doctor to prescribe a pill. I see this as a negative. No. 2, this whole approach to healthcare as sick care, we don’t address mental health until it’s too late. So we’re broadening the mental health lexicon and we’re addressing problems only until symptoms appear. I’m assuming you agree that we can’t view healthcare as sick care.
Gabriella (42:01): This is the huge part of a philosophical shift that these sciences are advocating for. If you think about the term mental health, what comes to mind? Therapy and DSM. When you think about physical health, the gym comes to mind. This is not part of the healthcare system. We’d love to see mental health be about how we take care of ourselves.
One of the reasons that the DSM is expanding in this way is due to pressures of the system where if I’m a therapist, and need to get paid, insurance is the one paying me and in order for me to get paid, I need a diagnosis. I need to say, “Here’s what’s wrong in order to get paid” when in fact, there might not be anything wrong in a normative sense. This is unfortunate. There’s a lot of pressure on the clinical side to diagnose things that don’t need to be diagnosed. We end up with higher levels of diagnosis. And on the non-clinical side, we have a journey to get people to think about their mental health proactively, preemptively and in an aspirational way. We should be proud of how we’re showing up psychologically.
Bambi: I read about Corey Keys and the concept of languishing, which is defined as a state in which an individual is devoid of positive emotion toward life. I’m languishing, not every day, but I do languish. It seems to me that we risk broadening diagnoses around our well-being. My concern is does it get into the DSM? Or do we create another bible for the spectrum of well-being conditions that are normative in order to get paid?
Gabriella: Languishing is such a great term to describe this middle space where a good portion of us have spent some time. We shouldn’t pathologize it. We shouldn’t have a diagnosis for it. We should recognize that part of our human conditions, there are things we can arm ourselves with to get to the point of flourishing.
Bambi: Insurance companies don’t need to put a clinical label to pay for it?
Gabriella: I hope the paradigm is more like a gym membership.
Bambi: What happens to you Gabriella in the next five years?
Listen in to hear Gabriella’s answer!
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