JOSH: Hello, and welcome to Clearer Thinking with Spencer Greenberg, the podcast about ideas that matter. I'm Josh Castle, the producer of the podcast, and I'm so glad you joined us today. In this episode, Spencer speaks with Daryl Chow about supershrinks and evaluating therapists performance.

JOSH: Before we get into the episode, we wanted to let you know that EA New York City is hosting Spencer for a live recording of the Clearer Thinking podcast on January 30th, 2024. The event is titled: "The moral status of insects and AI systems, and other thorny questions and global priorities research, with Jeff Sebo and Spencer Greenberg". If you'd like to attend in person, you can register either by clicking the link in the show notes or by visiting effectivealtruism.nyc/events!

SPENCER: Daryl, welcome.

DARYL: Thanks for having me.

SPENCER: Many people in the audience who are listening to this have probably been to therapists or who at least have had loved ones go to therapists. And today I want to talk to you about what I think is a super interesting and important question, which is: How well does therapy work? How can we do therapy better? What are the actual active ingredients that make therapy work, when it does work? So why don't you start by telling us about your investigation of so-called supershrinks? What is a super shrink, and why did you investigate them?

DARYL: It's a funny term. The supershrinks project began probably more than a decade ago. And before me, there were people — my mentor and my co-author, Scott Miller — who's investigating this idea of what makes some therapists more effective than the rest. And the start of that was basically borne out of sheer frustration when, as a psychologist, I'm originally from Singapore, working there and I'm trying to learn as best as I can. I did very poorly in high school and if you know anything about being in Singapore and Asian, you get a performance is everything. But then after, when I got out of high school, I had to go into the army, and I came out not knowing what I wanted to do. But then, figuring out that, "Hey, maybe this is one area that I feel really pulled into." I wanted to learn as best as I could. But the learning was always focused about doing one model to the next. And later on, I discovered the research evidence suggests that models account for less than zero to one percent of the outcome. And instead, the lion's share of differences lie between who the service provider was, who the therapist was.

SPENCER: So could you elaborate what you mean by model, and when you're talking about the variance and outcomes being attributed to the model?

DARYL: Models just basically means the theoretical orientation or the school of thought that you come from. So you could be cognitive behaviorally oriented, you could be emotion focused, you could come from a mindfulness-based, or you could come from schema therapy. There are hundreds of different schools of thought, and one touts to be better than the other. So you go through the continuous education track as a therapist. You try your best to learn about all of these different things, and you feel you're missing something. You feel like, "Oh, maybe I should learn that. Maybe I should go for that training about trauma and so on." These things are good to have, but it doesn't differentiate. It doesn't really account for what contributes to the differences in therapies. Which is why when I mentioned that zero to one percent, models account for a very small proportion of the outcome of what helps somebody who's seeking therapy. Instead, the large proportion of that is due to who the therapist is. So it does beg the question: What exactly is that, and are there some things that are learnable? Are there things that we could do? This got me down the rabbit hole, and I decided that perhaps I should make this a bit more formalized. And that's where I decided to go back to school and do my doctorate on this topic.

SPENCER: So when you talk about differences in who the therapist is, we could imagine different things there. One thing we could imagine is that it's about training. Another thing we can imagine is this, "No, some people just have the right personality," or, "They were made to be a therapist." There's also a potential explanation which is more a statistical fluke thing. Let's suppose that everyone was equally good at therapy, but you did a measurement of how well their patients did, or any measurement really, just through the statistical error you'd find that some would look better than others, just the same way that if people competed in a coin flipping competition, somebody would win, someone would lose, even though nobody is better than anyone else. So we can kind of look at these different factors that could be about who the therapist is. So when you're talking about that, what do you really focus on there?

DARYL: One of the things that we're trying to focus on was exactly trying to clarify that question of: What makes a therapist produce good outcomes? Because, like you said, you could see an average therapist, and you could actually get pretty good outcomes with that person. Because, as we know, the effects of psychotherapy are good. And in fact, the generalization effects — meaning, if you're focusing on something about your inner life, your emotions, it may spill into your relationship or in your occupational life. The results are robust in that way based on 40-50 years of studies in psychotherapy outcomes. But here's the thing: most of the literature at that time when I started was focused on master therapists. The definition of master therapists was "peer nominated by other colleagues who think that you are good at what you do." And I thought, that's kind of insufficient to categorize someone as being a highly effective person. So when we dug in a little bit further, we thought that perhaps a better way to define this was therapists who were consistently achieving reliably good outcomes with not just a single client, but with a pool of claims, and that they are measuring their outcomes. That was the tough part to find a group that was doing that. So we had those criterias in mind, and we have to figure out where a pool of therapists that were doing that consistently so that we can take a step further and interview and figure out their work practices and the things that they do to get better.

SPENCER: So how did you actually end up doing that research? Who were you able to study that was collecting outcomes?

DARYL: Yeah, I was on the brink of actually not finding anybody until I bumped into an old friend, an Irish friend, Bill Andrews. He's originally from Ireland. He's a really interesting guy. He used to be a dentist who changed profession to become a therapist. And he managed to create what they call a Practice Research Network in the UK. And basically, this group of like 60-70 therapists spread across the UK agreed to come together, measure outcomes consistently, and they did this for five years to track their patient or client outcomes for five years. And he said, "Would you like to mine that data and then take a step further to interview and to get some of them to do some questionnaires about their work practices?" And I said, "Yes, please." And that's how we started and we wanted to figure out what they were doing, what differentiates them, is it something about their mindset, something about their personality? And we just wanted to find that out.

SPENCER: So can you tell us a bit more about the data set? How many total therapists was it, and about how many patients did each therapist see?

DARYL: Yeah, so it was two studies. One was a subset of the other. So we had 69 therapists in the first group, and then would bolt down to about I think 16 therapists, who we follow up a little bit more. And I can't remember the exact number of clients they saw, but it was in the thousands. The criteria we had was each therapist was to have at least, I think, 15 number of clients. Because if the number was too small that they were seeing, if they had too small a caseload involved for us to look, the data becomes unreliable, like you said. So we needed those criterias involved. And then we asked for voluntary participation for the follow up second study, because we wanted to find out about some of their work practices. So we're drilling down. What we did from that first study was we were able to rank them, and we were able to see reliably who the ones getting really good outcomes and who were the ones getting 'okay' and 'average' but still not as good as the highly effective therapists. So that's when we started to pass out and wanted to find out some of the activities they got involved in. And this was entirely borrowed from K. Anders Ericsson — you might know him, the late K. Anders Erickson used to be what we call the expert on expertise — he had done some seminal studies about peak top performance in music, in medicine and sports. And none was done in psychotherapy at that time. And we thought we wanted to glean to do some initial studies. We're basically in a discovery oriented mode, and we took some of his ideas and ran through that. And the frustration about this was kind of felt in our field one time at a conference. Somebody in a conference, while I was presenting, just yelled out and said, "Daryl, can you just tell us what to do?" And this was a bunch of therapists who were trying to figure out what best to work on. And the thing was, we didn't find any particular one single activity that said that this was a huge predictor of outcomes. Instead, what we found was very nuanced, individualized things that people had to do that were helping them to go at their growth edge. However, one of the few things that we found was the amount of time that a therapist devoted to focusing at improving at their work and helping their clients. Meaning, the amount of time they spent working at this outside of the therapy hour, turned out to be a significant predictor of where they stood in the outcomes.

SPENCER: One thing I wonder about, if you were to take therapists that had good outcomes on, let's say, five patients, and then you look at their next five patients, how predictive would that be of the next ones? In other words, how much sort of correlation across time is there at being good? I know this is something that's been looked at in finance, for example, where you could look at, let's say, hedge funds, and you look at their performance over five years, and then you say, "Well, how much does this predict their performance over the next five years?" And there's certain situations where, in fact, they found very low correlations, in certain areas of finance. If I recall correctly, I think mutual funds didn't show a lot of correlation. So, I'm wondering if you did that kind of analysis?

DARYL: Not in our study. But I think Zac Imel, another researcher in this field, looked at that very question that you asked: How reliably does this translate to the next pool of clients? And it turns out to be consistently reliable that if we could predict the initial set of, say (I can't remember the exact numbers), 10 clients that they see, there's a huge chance that that is reliably transferred to another pool of new clients that they see. In another piece of work that was done by Bruce Wampold and Zac Imel, they wanted to find out this thing about 'alliance', which is how well the connection between the therapist and the client, the focus on the goals and the method, that's what we normally define as the 'alliance'. They wanted to find out how much of it was due to the fit between two persons, how much was it due to actually the client, maybe some clients are just socially responsive, and so on, and how much was due to the therapists? Just a few days ago, I was running a training and we were asking people this question. Most therapists would argue that it is the fit. Most people would say that is due to the fit between two persons. But what this particular research that they did was to disentangle the correlations. And they found that a huge proportion of the variance of how well the alliance is formed is due to the therapist. The variance is kind of unheard of in social sciences. Barely 97% of the variance is due to who the therapist is. Meaning to say, we can speculate that, perhaps, some therapists are really good at this ability to facilitate and engage with a wide array of different folks. But if I could add, one of the things that we thought, maybe things like years of experience, the profession that they come from — maybe they're social workers, psychologists, or psychiatrists — or maybe all these kinds of static factors might account for something. It turned out that years of experience doesn't predict how well somebody does in the outcomes as well.

SPENCER: That's super interesting. One thing that confuses me about that a little bit, is that you mentioned that time focused on improving outside of therapy was predictive. Do you think that people who had more years of experience just would have had more cumulative time focusing on improving themselves? So is it more the time-focused per year on improving yourself as predictive, but the total cumulative time is not as predictive?

DARYL: Yeah, that's a good nuance to disentangle. The thing that we kind of asked initially because honestly, this was just the first study we've done. I'm not sure even if this would replicate, if more studies were done about this. But initially, we just wanted to know, just to look back at your typical work week. We asked them to literally go through the schedule, see the people that have met, prime with actual situations, rather than abstract self-reporting, and just look at how much time you spent working at improving the caseload. So we're just kind of doing that in terms of the most recent engagement that they had in the typical work week. So it's kind of hard to say whether or not that actually transpired to they've been doing that consistently or not. Perhaps, possibly, they probably might. But here's the thing: I think some of the stuff that is coming out of training as well — so in terms of how much time people invest in training, formal or continuous education — training has very little impact on your outcomes as well. And this is not just one study, this is now a handful of studies that have come out about this. And the ability for what we've been calling the facilitative interpersonal skills — meaning the ability to engage with people in therapy — was predictive of outcome. But that ability that was measured is before training happened. Meaning to say, some people seem to have this ability to do that, and training seems to have a minuscule impact on whether it helps to bring that up.

SPENCER: So far this suggests, if this work were replicable, that basically what matters is this sort of ability to build an alliance with your patient, and that this is something that is really about the therapist themselves. It's not about their training. Maybe the amount of time they spent focusing on improving is irrelevant, but who knows, maybe that's just a proxy for how much they care or something. But I imagine you've done a lot of other research since and others have also done research. So as this field has developed and more and more studies have been done, what kind of broader picture started to emerge?

DARYL: First up, just to be clear, I'm not an academic researcher. I don't belong to any university. So a lot of this stuff that we end-up doing after my doctoral was basically independent research. So it was kind of hard to churn as fast as we would like, but that's it. One of the things that we wanted to get clarity on was to take some steps further based on the initial supershrink project, and to see if some of these things were scalable and learnable for helping people. So we decided to take one step further, and we did another study called the Difficult Conversations in Therapy project or DCT. We really wanted to see if we could apply the principles of deliberate practice. So in short, what we did was present therapists scenarios of typical but rare, but does happen, situations that were challenging, and to see, in a frame, an environment of learning, whether therapists can improve. So we randomized that. The control group were to engage in learning by themselves and to take some time to reflect. And in the feedback group, what we did was number one: we didn't tell people what the right answer was, we didn't tell people how they were scoring as well, but instead, we gave them principles, some ideas of how to think about the situation, and then to say it in their own natural voicing, their own stylistic semantics and how they would word it. And what was interesting in that was that the control group, by and large, were very active in the reflection, but then actually did not improve in their outcomes. On the other hand, to no surprise, the feedback group did improve. But the interesting thing was that when we changed the scenarios, they were able to generalize that into the other scenarios and were still able to do that. And the surprising thing for us was that we also asked them to rate their own self-rating, meaning to say, "How well do you think you did?" And the feedback group, as they went, they actually started to doubt themselves more as they went along, even though their responses were actually improving. So that's kind of surprising to us. That's something that we hope we could take it a little bit further down the road.

SPENCER: That's really interesting. So with these difficult conversations that you're having them go through, how did you grade them? How did you know what the right response was?

DARYL: Yeah, that's an interesting one. So basically, what we did was we borrowed the framework from another researcher, his name is Tim Manson — I mentioned the FIS early on, the facilitative interpersonal skill — so he had this little grid of how you would score somebody, how they will respond with warmth, persuasive response, somebody who is compassionate, so we were using those benchmarks as a reference point. But then again, it's hard because the thing that we do in therapy, it's not shooting a basketball hoop. It's not a clear kind of environment where you could tell where it lands on, because it's very dynamic socially. So what we had to do was to see if we as the raters — there were two independent raters — felt that those things hit a resonant note: whether they were relevant to the point of, or whether it provided a dynamic empathic movement forward in the conversation.

SPENCER: Got it. Does that basically mean that you show that they were able to learn these skills of showing warmth, showing compassion, saying things that are relevant? So you basically were training them to apply those skills and then you demonstrated that they, in fact, learn the skills?

DARYL: In a way. But the distinction is that we were not fishing for right answers. So we had no predefined, "Okay, here's the best way to respond." So what we were really aiming for is positive variance. We want the people to just try whatever ways that they did. But if it hits that note, so to speak, then it sort of makes sense. Maybe the best way to put this is: it's easy to train and get good at an instrument because you know that you play a scale fluently, you know you've got it. But playing an instrument well is very different from writing good songs. Because good songs, as much as they may be some kind of pop formulaic way of doing, those who are more cutting edge in writing good songs don't really have a formula for that. There's a form, there's a structure, but you never know what you're gonna get. So what we wanted was people to respond in their own way. We were just trying to guide to see if there was little feedback we could give to help them edge a little bit further towards something more.

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SPENCER: So if you had to break down your view now on what the elements that go into being good therapists are, what would you include in that list?

DARYL: That's a good question. We recently talked about this in one of our blocks in Frontiers Friday. So I think there's a combination of three key things. The first one: I see this a bit like an iceberg, actually, where in the middle piece, that's the craft, so it floats a bit above, slightly on the water. The craft, meaning, how much you devote time to work at this deliberately to improve at your edge. And then the top piece is what I call creativity. So you have to have enough flexibility to engage with different people and also be playful enough to try things out and be responsive enough and improvisational enough to listen carefully, whether this particular approach sits well and whether it is cogent with this person. So you've got to be really adaptive at the top end things. But at the bottom end is care, that the ethics of care, meaning that you got to come from a place where you are humanizing enough and not always just trying to optimize, but you gotta be able to slow down, you got to be able to let go of your pet theories, and you got to be able to attend to the human in front of you. So the combination of care, craft and creativity, I think they sort of stack up. But some of the other things that we found in the initial study sort of hints at this. One of the other things we found was that the highly effective therapists, strangely, had two other factors that were differentiating their own self-perspective compared to the average practitioners. One of them was that when we asked them to rate what other researchers would call healing involved in, meaning to say, if they appraise himself, how much do they feel they're engaging, efficacious, affirming, and all those Carl Rogers' "Rogerian" Factors of being a good therapist, how much do they think of themselves? So we got them to rate that. And it turns out to be a significant predictor of outcomes actually. And the thing was that it was significant. However, it was inversely related. Meaning to say, that the more effective therapists were slightly more compressed and a little bit more doubtful of themselves compared to the average practitioners, if that makes sense.

SPENCER: So maybe they hold themselves to a tougher standard?

DARYL: That's right. And then the second piece was that: we asked them as well to think back specifically to their caseloads that they're seeing and to prime their working memory about that. And then we asked them, "How many times, not a rating of degrees, but how many times were they surprised by the clients feedback that they've got through their work with them?" Meaning to say, that they didn't think that the clients would have that viewpoint. And it turns out, the highly effective therapists rated more times of being surprised, relative to the average practitioners. In other words, they were engaging in what some researchers would call hyper-correction. They were willing to change their minds, they were willing to throw out some of their original views and adapt to the situation. And I think that's a really important thing because you could read a study that says, "This particular approach, say, maybe CBT — nothing against CBT but let's say cognitive behavioral therapy — works very well for anxiety." Sure. On average, that sounds good. But that's an ecological fallacy to think that what works for a so-called average person will work for the individual right in front of you. Because if we make that conflation, there's no such thing as an average person. You've got this specific person in front of you, and you've got to tap into that person's belief system, world views, and to be able to work with that.

SPENCER: Yeah, that's really interesting. When it comes to creativity, like sort of flexibility or ability to improvise on the fly, that makes a lot of sense to me intuitively. Because when I try to help friends dealing with problems when they come to me, it often feels that the way that I can help them the most, besides being an empathetic listener and validating their emotions and so on, which maybe would go into care, is that sometimes I can help them see their situation in different light. So it's not that I'm giving them an answer, but maybe through our conversation they come to see their problem differently. And to me, that takes a lot of improvisation of adapting to what's actually going on and what they're saying.

DARYL: Totally. And I could imagine, sometimes when we speak to friends, we also would use certain metaphors and an analogy to get a point across, and maybe it doesn't land and you try a different view as well. So you gotta be responsive enough to how one is receiving it, because it's a jam. You have to try it out to see if it actually works, which is why I think it's kind of dangerous for therapists to go in with what I call a 'pill model approach'. A pill model approach basically just means, you know so-called what works for whom, you try to stick to the models, and then you just deliver the best thing that you know is evidence-based, so to speak. It's important to learn that, but I think that's necessary but insufficient. Because instead of a pill model approach, you need to have a continuous calibration approach instead. You want to try it out, you want to see how the other person responds to you, and to see if that resonates or not, and then you got to try to adapt, you got to try to recalibrate, you got to try to adjust to see if something actually sparks for that person.

SPENCER: On that point, I've seen a number of studies that have gone to manualized therapy where they say, "We're going to not just have people do CBT, but we're going to actually train them to do CBT the same way. And then we're going to pit that against, let's say, having people do it their own way, or people who haven't gone through a sort of manualized process, etc." And my understanding is that — I'm not that deep in the literature — from a surface level, the manualized versions of therapy work as well as the unmanualized versions, so that by standardizing it, they don't make it worse. Is that your understanding of that literature? And I'm wondering how that meshes with this sort of flexibility or adaptability thing?

DARYL: Yeah, I think there's some nuance to that. And I think one extreme example we could think of is a synchronistic online where somebody goes into a program for, say, CBT for generalized anxiety, maybe. And in that model, you could ask the question, "Okay, so where is the alliance and that sort of thing?" But think about this: for people to go into that program, a couple of things happen. One of my colleagues in Singapore, Sharon Lu, has done some studies on this. And she found that if people agree to be on a program in that way, that means that they are okay and they would likely engage in that process. So there is a kind of alliance to the framework of the fact that they're going to consume information that way. But the other thing she found was that the dropout rates are really high. I don't know what exactly the dropout percentages are in those situations, but the dropout rates are high. But the dropout rate starts to diminish when they have some real human on the site, just dropping them an email or checking in to see how it's going, and whether they engage in the program, just having somebody side-by-side with them makes that level of impact as well. So in short, I guess, client preferences are really key. They are just so important. So for example, if a client comes in and now taking away from the online world and to more face-to-face, if a client has a certain preference — let's say they want to meet somebody with a spiritual viewpoint, religious background, or belong to certain ethnic community — we don't pay attention to that if they have some specific preferences. We actually run the risk of not being able to achieve better outcomes than we could possibly do. So to attend to these specific things is really important because client factors — in what we know from the research at large, not just one single study, but composites of different studies — account for about 80 to 87% of the variance in client outcomes. That's huge.

SPENCER: And so what does that mean client factors?

DARYL: So client factors, meaning, if they have preferences, the resources that they come in with, the relationships in their lives, some of their background, things that may be extraneous as well — maybe they just got fired from a job, they lost the job, somebody got ill enough in a family, or something good happened in their life — these things, they're outside of therapy that's happening in their lives. A therapist needs to do their best to utilize and tap into those pieces and weave that into the mix in therapy. Those accounts for, like I mentioned, about 80 to 87% of the variance in outcome.

SPENCER: Another question I had is about that factor craft that you mentioned, this idea of working deliberately to improve. What is it that the therapist should be working at exactly? Is it those other factors you mentioned previously — like being more warm or compassionate, more persuasive, more relevant — or does it not seem to matter as much what they're working on, as long as they're working at something?

DARYL: This is a really important question in the field of psychotherapy because every other training and workshop is trying to tell you what to work on and how to do it. My co-authors and I argue that there's a couple of sequences that need to happen. I think the first step is that you have to figure out a way to make sure that you are consistently measuring outcomes of your clients so that you could take that feedback ongoingly in real time and feed it forward. In other words, you have to figure out a way to integrate the use of taking measures to guide your work so that the data set can change your mindset as you go. That's one. After that, if you do this reliably and consistently, you will have a body of data. So you would like to have at least close to 20 to maybe even 50 cases, then that's where you could get a reference point. You could get a baseline of 'where are you' before 'where you need to go.' So you look at your own data on an aggregated level. And this is the key. This is now your N=1 as a therapist with X number of clients. And you're not just outsourcing decisions based on some other external study that's done there, though useful to know, but you also need to get down to the ground and find out where you are with things. Then the third step really is to figure out the 'what' that you need to work on based on your baseline. Then you get to the 'how' later. So the point of frustration is this: every individual therapist needs to figure out the 'what' before the 'how.' I think in some way, the trouble with this level of thinking is probably in part due to our educational background; we are told what to learn. But in life, we gotta figure out what exactly we need to learn that's at our growth edge, or sometimes referred to more formally as the zone of proximal development. That growth edge. we need to figure that out. And for one therapist, maybe it's about figuring out how to explicate warmth. Maybe for another therapist it's about how to structure the sessions. So it's pretty nuanced. And then after that, to wrap it all in, they need to develop a kind of learning system, something that's sustainable ongoing. So they need to have something that's guiding them into practice. Because a lot of what we're trying to do is to be of service to someone. We give ourselves, as far as we can, to help somebody in need who's in distress. But then outside of that, we also need to bake in ways that we are nourished, we are growing, and developing in a way that's actually helping locally the people that we are trying to help. To us, that's currently the working framework about how someone can engage in deliberate practice.

SPENCER: So when I was younger, I saw a few different therapists. When I was very young, I went to, I guess maybe more of a kind of Rogerian-type of therapists who just listened to whatever I would say and kind of reflected it back. A bit later in my life, I went to a couple of cognitive behavioral therapists at different points. I haven't been to a therapist in quite a number of years, but I do sometimes see coaches and I have this thing I do where I'll meet with a coach for five sessions, just to learn about their style and their approach and to see if they can help me with something I'm working on. And then I'll try a different coach and I kind of go to different coaches. And so I have a bit of a comparison point, looking at the sort of different approaches that the therapists and coaches take. And I have to say, I have not ever experienced one of them collecting data on how they're doing. I have not a single time had me fill out a feedback survey or anything. And so I just want to say I'm such a fan of the idea of collecting data, and I actually don't think that people normally give that data. You might think, "Maybe they just know how they're doing." And I think the answer is, no. I don't think they would know how they're doing. I think that patients have a lot of social pressure on them to sort of act that they're improving or that things are fine. And so, I'm just curious to hear your reaction to that.

DARYL: I think you hit the nail on something really critical. And earlier, I mentioned that little framework about integrating the use of measures is the first step. This is the one biggest step that many people in the mental health field are stuck in because it's not part of our tradition, it's not part of the way we think. To me, it's not about quantification. The use of numbers for me is to leave numbers, so that we can check our blind spots to just make sure that we are not deluding ourselves. And it's not because we are just purposefully deluding ourselves, it's just that it's blind spots. Sometimes we just don't see it. I'll give you an example, something that we use at workshops. I will present a real case and we'll talk about the situation. So maybe in this case, somebody who was suicidal, one who was really low in their mood and had lots of trouble relationally. Then I asked him to predict from a particular measure. For the ease of your listeners, this is a 0 to 40 about their well being. So I said, "Imagine the form was given to them. And it takes about 10 seconds to score these four-item things. So it's about their individual wellbeing, their close relationships, and then how they're functioning socially at work and with friends and overall. So these four things add up to 40. Make a prediction where you think they would score." So most therapists given that clinical profile will lean in to their expertise and their prior knowledge and then make a gauge, "Okay, I think the person would score, say, 10-12," which means this person is likely to be in distress. Well, I would score that too. But then I said, "If the form was given to this person and it came back at 28 points." So again, for reference, if this person is scoring above 25, that's our clinical cutoff. Meaning to say, if you score above 25, you're likely to be in the range of actually coping well. So in this case, this particular client tells you about the situation, but then scores it that way at 28. What happens in your mind right now? And I think that's important because the aim is not to outsource decision making purely to numerics or some kind of scale. The aim is not also just to rely only on your clinical intuition. My hope is that we marry clinical intuition plus the data that's given specifically. And here's the key: the data is not expert-rated. It is not rated by the clinician; it is rated by the person you're trying to be of help with. You marry these two together to make better decisions, and hopefully, learn and update, and then become more responsive in real time. And then if you see the discord (back to the example of that person who was feeling suicidal and low in mood but then rate it that way), hopefully it should inform you to ask questions differently. Like to say, "I don't understand, how come you are scoring that way?" And the person might say that, "Actually, things have improved." And then if the person said things have improved, even before therapy started, the next sensible, intuitive thing to ask is, "What changed? What did you do?" And the person might reply, "I finally talked to my parents and my brother about the situation, and somehow we came closer to that." And then that's where the adaptiveness is; you want to tap into that. There's something about the preciousness of significant relationships with this person, and you want to inquire a little bit further, if that makes sense.

SPENCER: Yeah, that example really resonates with me because I'm the sort of person that tries to predict a lot of things. And by doing this process of regularly making predictions, you realize how much you don't know. Because you make a prediction and you're confident, and then you're wrong. And you make a prediction, you're confident, you're wrong. And over time, you get a little bit less wrong, a little bit less wrong. Over time, you get better.

DARYL: Hopefully, you can be wrong about new things after that. [chuckles]

SPENCER: Yeah, you get wrong about new things. And also, you learn. That's how you learn. The thing is, if you see the answer without having sort of made a prediction first, then you don't learn nearly as much. And if you never see the answer, then you learn the least of all. You never find out. So that makes a lot of sense to me that that's a really good way to maximize learning. And I think this applies just so much more generally to many things beyond therapy. This idea of creating feedback loops with whatever you're doing, and especially feedback loops that surprise you and teach you things about what you're doing well and what you're doing badly, so you can improve.

DARYL: Oh, man, you're getting me really excited about what you're seeing there. And can I just say this? So one of the things that I've been doing lately, for my own purposes, is that whenever I buy a new book — I'm obsessive about learning as much as I can; maybe it's because of an overcompensation for my history — but when I read stuff, the thing is there is kind of a fluency illusion. When you read something, you open up and then you pour into the book, "Yeah, that's so cool." You learn stuff. But I found that that illusion is kind of peculiar. Because once I close the book and some time passes, and then I'm imagining, "Okay, we learn about that from Charles Eisenstein about this." And then imagine if I'm trying to tell a friend, "I can't squeeze in one minute of information from there, I forgot quite a bit." And I thought, "Okay, maybe a better way to read is, I get the book, I look at the contents page, maybe I look at the blurb at the back a little bit, and then I make a prediction." Just kind of, "Okay, what do I know about this? What do I know a little bit about this topic?" And I just try to flesh that out quickly, maybe mind map it out, and then I read. But I find that when I read that way, there's a schism in my head that I'm so hungry to close and then, "Wait, how is it I got that wrong? How is it that I didn't think about that?" And then, it sort of drives you in that it pulls you in. So back to the therapy world, one thing that we also tried to playfully encourage therapists to do — so we talked about measuring outcomes — but I also encourage therapists to measure their engagement level. So a quick way to measure how the therapy went — and interestingly enough, highly effective therapists tend to get lower alliance ratings initially compared to average practitioners, which does suggest that the way that they're asking seems to encourage a wide range of feedback. They don't feel that their ego is at stake, they're willing to take in. But anyway, to the point, I do encourage people to do a playful thing, probably exactly what you're saying, Spencer, is to make a prediction. Ask their rating on the questionnaire. They quickly scribble down what they think that they would score, Because the aim is not to seek to be right; the aim is seek to be wrong, to be disconfirmed. Because if you got it wrong, you're more likely to elicit some feedback to take that forward. So for example, if you thought everything went pretty okay, let's just say everything was 9, 9, 9, 9. The client may be rated 9, 7.5, 9, 9. And the 7.5 turns out to be about focus and the goals of the session, "Did they talk about things that the client wanted to talk about?" Now, if your prediction was wrong, you want to find out, you want to go, "Oh, I'm so sorry. We went on talking about your anxieties, but it seems maybe because it's the first session, maybe we ran out of time, but I'd just like to know what's something that you hope to cover grounds on that we may not have had a chance?" And then a client might say, or at least in Australia, people like to say, "No worries, it is all good and all that." But because of that gap between what you predicted and what the person scored, you may just kind of gently prod a little bit and push and say, "It's okay, I just like to know, so that I could plan it forward." And the person would say, "I hadn't really given it much thought but this thing still sort of looks at the back of my mind about an abortion I had a year ago. And maybe, I'd like to see if we could talk a little bit about that." And then the therapists just need to make sure they acknowledge, take their feet back in, and make sure that's part of the treatment plan going forward, at least to explore that.

SPENCER: This reminds me of a situation I had with a coach I once saw, where the coach was telling me that they thought that some of the stress I was feeling might be due to what they describe as intergenerational trauma, which they defined as sort of trauma that can be passed down through the generations, not genetically, not like, "Oh, you have a genetic predisposition." But somehow, because my great grandparents had trauma, maybe I'm experiencing that. Actually the first couple of times she brought this up, I kind of just ignored it. Internally, in my mind, I had a very negative reaction to this because I don't believe it exists, at least not in the way she described it. But I didn't say anything. I kind of suppressed that feeling because I didn't want to make her feel bad or make it an awkward situation. But the third time, she brought this up. I was like, "Okay, I gotta say something." So I just mentioned to her, "Oh, yeah, I don't believe in that. I don't believe that that is actually the thing." And then the therapist spent the next five minutes trying to convince me that it's been scientifically proven that generational trauma exists. And that just turned me so far away from this therapist or this coach, where I just had such a negative feeling at that moment. And I feel that the coach was so poorly tracking what was going on in my mind. And if there had been that kind of feedback loop, where that coach had been sort of both collecting data and also open to hearing the data, I think it just would have gone so much better.

DARYL: I really like that example. I really like it and here's why: My worry in the field of psychotherapy — I hope I'm not phrasing this wrongly and I hope your listeners don't take offense if they're therapists out there — but I really worry about us colonizing our ideas onto people. Meaning to say, with good intentions, maybe a therapist comes from a trauma-focused perspective, maybe a therapist comes from a CBT perspective, it's very easy for us to impose our ideologies about these things onto another person when they may not have that viewpoint. They may not see it that way. Exactly like what you said, maybe you don't see it as an intergenerational trauma. But for another person, they might go, "You know what, I think you've hit the nail. I've always thought about this. I've never found the words to name it. You made sense." That's a totally different encounter, a different conversational piece that we evolved from there. But I think what we need to do is be honoring and respectful of a person's viewpoints first, at least as the first port of call.

SPENCER: It actually reminds me of another situation I had with a coach once, which I think also illustrates this in an interesting way, where the coach was bringing a very specific theory to how to do coaching. And they were asking me what I thought about it. My belief was around something, and I told them. And they said, "Oh, no. The theory says that that's not what you think." And I was like, "What?" They're like, "Yeah, according to theory, you can't actually believe that." And I was like, "What? Are you kidding me?" [both laughing] And it was infuriating, because it's like, "Well, fuck your theory [laughs]."

DARYL: Oh, boy. I had an experience once, as well, with a supervisor, and he was really good but he was coming from a particular modality of how therapy should be done. I thought not too much of it, and as we went along, I presented cases to discuss. And then somewhere down the line, he told me that, "You need to present another case. It doesn't quite fit this model that we're talking about." I was like, "What? Seriously?" It's kind of strange. So I guess, in short, the dynamic nature, the musicality of our conversation is that it's emergent. It emerges from this co-creation process. The improv actor and teacher Keith Johnstone would say to actors, "Don't try to act well, don't try to be empathic and all that with the other person, the other improv actors." He said, "The one instruction I have for you is seek to be altered, seek to be changed." And I love that. I think it's so true because only something beautiful can evolve much like nature. It's so complex. You can never predict and you just gotta be willing to step into that river with them in conversation and to listen very carefully to their viewpoint. I'm thinking now of one example, if I may say this. When I was in Singapore — because Singapore is a hotbed of different cultures. And one thing from Chinese culture is that there is this belief of what they call like a fusion between Taoism, Buddhism, and ancestral worship, and mediumship (a medium is somebody that will get possessed and then descendents can come through that medium and speak and all that) — I had a client who was actually coming from that family of tradition. But when he saw us, he was actually diagnosed with a prodromal, sort of like early onset of psychosis. They were worried that he was losing his mind or something. And when I later on figured out that, actually, there was a whole other deeply infused culture at the back, which basically, this person decided that he doesn't want to be a medium, because he comes from a tradition of mediums in his family. And because of that, he was having all kinds of problems. Now, if you come from a westernized — Singapore is very westernized — tradition of medical medical view, you will go, "He's unwell, he's hallucinating and all that." But if you just kind of suspend that, you could hold two truths at one time, and just listen carefully to where they're at, then another story unfolds, and another viewpoint unfolds, and you could, at least, tend to that as well.

SPENCER: I feel so conflicted about this, because on the one hand, I think that there are some things that are true and some that are not true. And I believe that applies just as much to whether there's a table in the room I'm in, as it does to the sort of the nature of the human mind. I think there are truths about psychology and the way the mind works. Obviously, these truths are dependent on the person, because different people are different. On the other hand, I think that to work with someone successfully, especially in a kind of therapeutic context, it's so important to adapt to their own beliefs, to work within their own belief structure. Because if you're pushing up against it, if you're trying to force something into it, they're gonna be much less receptive to what you're saying. You're much less likely to be able to help them. So how do you navigate those two things? Aren't there truths about the human mind and shouldn't that imply that certain techniques actually are more effective than others?

DARYL: Yeah, I'm not so sure about that. [chuckles] I don't know. I think my best answer is that there are a multitude of different worlds out there that's beyond my comprehension. And that's at least my first port of call. But I'm also inclined to want to learn and understand as best as I can. There are areas in a material world that is something physical, but we're talking about somebody's inner life, somebody's inner life. It is absurd to state it this way, but that person is the only person who's going to experience that inner life. And I want to honor that, I want to make sure that I'm listening carefully to those things. And sometimes I may offer my perspective. And I'm not saying it's the right perspective. I'm just saying, "Is there another viewpoint that could help you become more alive?" Spencer, I think you had some writing before. You playfully call this a "philosophical disorder." Sorry if I'm butchering it...

SPENCER: Yeah, I wrote an essay about that.

DARYL: If there were viewpoints that they held that were holding them back, then I want to make sure that I at least start to help them loosen that up a little bit, play around with it, and to experiment in life to see if there are other alternatives that could help them come alive. It's really important. Another case in point: my father-in-law, he's about to retire but he's a Chinese physician. He's what they call a traditional Chinese medical practitioner, TCM. And you could argue from all kinds of viewpoints that it's unscientific: this thing about your body getting heated, or it's due to that, and you shouldn't eat certain foods and all that kind of thing. For some people, that's absurd. But in certain traditions, that makes total sense for them, and it helps them that way. So, I don't know. I think that the struggle we need to hold is to be able to hold different viewpoints, and to at least hold ours lightly enough. And if things don't go in a way to help us to come alive, then it is to think of other viewpoints that may be potentially helpful to experiment and play with. Because, as the late Jerome Frank said (I think if I'm not mistaken in the 50s or 60s), he calls psychotherapy a process of persuasion. And it's a process of healing endeavor that requires the emergence of two different minds, two different worlds to come together, and hopefully to become of one mind.

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SPENCER: Let me draw a distinction here because I think on the one hand, you can have a therapeutic practice where you're trying to shove an idea into a patient's mind that they don't agree with or doesn't resonate with the way they think about the world. And I think that that is a bad practice. But on the other hand, there's a sort of other thing here, which is that some things about human nature are truer than other things. Not all claims about human nature are equally valid. It's not true that most parents hate their children when they're born. It's more true that most humans love their children. Now, there's individual variation. Some people do hate their children, but it's more true that they have loved their children when they're born, than they hate them. And I think there are hundreds of thousands, millions of such facts about human nature. And I think some ways of treating patients are more aligned with the facts of human nature. So for example, imagine you had one therapeutic modality that says that the way you cure depression is by wearing red shirts and the way you cure anxieties were by wearing blue shirts. I think that would be less true than, let's say, a modality that says, "Hey, sometimes you have beliefs that make you depressed. And if we could somehow change those beliefs, you might feel less depressed." Or you could look at real examples. There's an old school of psychodynamic idea, in some psychodynamic schools, that said that children would get angry at one breast, and you have a positive view of the other breast when they were breastfeeding or whatever. And that's a claim about human nature. And I think that claim is probably false. Maybe you just disagree about what I'm saying generally, but I'm wondering how to square this with the idea that sort of the model doesn't matter. It doesn't matter whether we're doing CBT or treating people with depression by making them wear red shirts.

DARYL: Funny case in point about placebos. You give a blue pill, sugar pill placebo, to somebody, the blue color comes and goes down in general. But apparently, they said that if you give a blue pill to somebody in Italy, it arouses them. So cultural context really makes a difference. And why is that the case? I might speculate because blue is the color of their soccer team. So but of course, there are some absurd claims about human nature, about what we ought to do, which is why I think so much of the variance is also dependent on the therapists. The therapists gotta do something that they believe in. They got to do something that's cogent to them. They got to do something that they would apply for themselves as well, and it speaks to their personhood. it speaks to them growing as a person. And if that resonates for them, then when they are meeting their clients, they too have to make sure that these are the ways that they're working, and are sort of spelled out as well. And how much range the therapists have to adapt to a person also is therapist-dependent. So it's not that you just do anything, I'm not claiming that you just do anything. It's got to have a cogent rational, it helps through the process, it makes sense to the therapist and the client, and it helps that person come alive.

SPENCER: Isn't there more than just making sense to the patient and the therapist? Doesn't it also have to accord or align with the way the human mind actually functions? If it's just some random thing that has nothing to do with the way the human mind functions, okay, sure, you can get a placebo benefit. Presumably, you can't do better than placebo. But presumably, if you actually work with alignment with the way the human mind is, you could do better than placebo, no?

DARYL: Yeah. I think you can, especially if you align with the human nature of how we grow, how we develop, but also align with the idiosyncratic nature of that person's worldview. So of course, you got to understand how growth typically happens in terms of human development. So that's a thing that we do have to at least have some basic understanding of that. So some of the proponents now are saying, one of the key things in improving somebody's well being is the ability to have an openness to experience — sometimes viewed as a personality trait but it's something that you can encourage people to do — and then in turn to become more psychologically flexible. Sure, these things make sense to help people to increase their range. So if somebody comes in with, say, a kind of phobia and anxiety, then to help them volitionally take those steps to approach the thing of which they fear gradually, make sense to help them develop, so they're no longer in prison by their own fears. So I think, of course, you have to weave in things that are making sense from what we know in psychology.

SPENCER: It's so interesting to me, because it seems that you put so little emphasis on the truth about human nature and so much emphasis on the belief of the patient vis-a-vis the therapist, especially for the patient.

DARYL: I like that you pick that up because it's true. I think what we really need to do, at least for a person in my position as a clinician, is to hold our truth lightly.

SPENCER: I just want to ask a couple more questions that I think will be really relevant to our audience. So first, suppose that you had to find a therapist for a loved one and you can't recommend someone obviously you already know or go to your own, obviously you work in this area. But let's say you had to go online and find someone the way everyone else does, what would you be looking for? How would you make that decision on behalf of a loved one of whom you're going to say, "Hey, maybe we should check out this therapist?"

DARYL: Oh, that's a good one. I like this thought experiment. In fact, I was thinking of one for a friend recently. The thing I will not look for is the credentials. I won't look for that. I won't look for what kind of modalities they're endorsing on the website that they say they do. If I can, I want to make sure that I at least know them. And better still, if they're actually systematically tracking outcomes, that will be ideal. But I also want to know that they have that level of warmth and care, and they have the skills, the know-hows to work with them in that area. And I know this sounds silly, but I always want to make sure that they're licensed. Meaning to say, that if something goes wrong, there is a governing body, maybe if they are a registered psychologist, let's say, that's there to fall back on. So my bias is definitely to go towards someone I know and if they are also tracking outcomes in real time with their clients.

SPENCER: So suppose that a listener goes to a therapist, and they have their first session. What kind of factors should they be looking for in that first session or maybe the first two sessions that could give them an idea of whether this is going to be a good therapist?

DARYL: Oh, yeah. My advice for that is that if you are a client seeking help, especially in the initial session, I think the first thing is: do you get a sense that your therapist likes you as a person? I think that's a very important and maybe taken for granted thing. You want to get a sense that they not only are being professional, but they are personal. Because in our job, the paradox is: the most professional thing to do is to be personal with someone, to not treat it transactionally but to treat them with a level of honor and respect for their situation and them as a person. That's number one. Second, that you might have some things in mind as a client that you want to work on. And those may be the obvious things. But what about the unspoken stuff? Do you feel safe enough to bring that up? And if not, was the therapist responsive enough to adjust, recalibrate, and attend to you? And then finally, do you feel, especially the initial sessions, is it just a Q&A? Like they're just asking you a bunch of questions, and they're just doing what they call an intake? Or do you feel like out of that, there seems to be a pathway forward, either concretely or implicitly, that there is not only some hope, but you feel like this could go somewhere, this could help you? I think those are really important signposts to look out for. I spent a whole book talking about this, called The First Kiss. It's not a romance novel; it's really about first sessions geared towards therapists. And one of the things that happens in our fields, quite a bit of a scandal really, is that: even though the average number of sessions is four to six internationally, but the modal number of sessions, which means the most frequent number that appears, is one session. About 20% to 30% of clients come for one visit and decide that this is not for them. And the real question is: Do therapists know that that's happening in real time? And are they able to pick that up to readjust that they have actually had one foot out the door, even after going through the barriers of, "Oh, my goodness, shall I speak to somebody?" And they finally took that step to see somebody and to speak to a stranger about the emotional difficulties. So yeah, the therapist has to make sure that they are aware of those base rates that typically happen, but also to be able to have safety nets to catch that.

SPENCER: One thing I've observed in my own life, talking to friends who've gone to therapists, is that they often seem to be hiding information from the therapist, not so much to sort of give the therapist a false impression, but more that there's something they're unhappy with in the therapy or the therapy is not focusing on exactly what they want. And they'll tell me and I'll say, "Have you told the therapist?" And they almost always are like, "Oh, no. I haven't told them that." I'm like, "Can you tell them, please?" But on the other hand, isn't it sort of the therapists job to make them comfortable? But I guess my question here is: I have the sense that people often aren't as forward with therapists as would be beneficial. And I'm wondering what you think about that?

DARYL: I think I'm at fault for that too, as a therapist. I think that can happen, whatever excuses I come up with myself about timing, about pacing myself, but it's true. I'm thinking about when I sought help as well, the first time I saw someone, I probably said a sentence of words. And it was not related to my problem because I was so overwhelmed — it was about 17 years ago — I just didn't know what to say. I just ended up talking about the map that's on the wall. And he respects me for that. And I didn't talk about the unspoken. But there's something about him holding that space that made me come back and see him, and our relationship and our work started later on. But I think for therapists, it's kind of important for us to pay attention to three things: what they will say, what they won't say, and what they can't say. Those have got three levels of implications. The 'will say' are things that are obvious. The 'won't say' are just a little bit underneath, it's a bit painful and distressful to get to. The 'can't say' has got something maybe covered with shame, maybe self-referential about their beliefs that they feel that they are unlikable, and it's bizarre to say something like that. But we have to really pay attention, which is why the tempo-rhythm of a conversation in therapy versus one that you and I are having or something that we have with friends is very different. It's very much softer. It's very much slower because it's a bit like approaching a wild animal. I'm not saying that clients are wild animals. But emotions, if we approach them like a wild animal and we just jump in and go, "Okay, let's look at this now. Ta-da." You're going to scare the wild animal away. It needs to be encountered. You need to let that animal see you, and then you take little bits of steps in, and to see the response of that. And then slowly, slowly approach that. So it's tricky, man.

SPENCER: What about feedback about what the therapist is doing? When you're working with a therapist, and you kind of feel, "I don't really like when they do this," or "We're not really doing this the way that I want." Would you encourage patients to bring that up with a therapist or would you say the fact that they feel a struggle to say that bring that up means that they might not be the right therapist for them and they should seek another one?

DARYL: My colleagues, Ben and Carrie, have this really fascinating podcast series called Very Bad Therapy Podcast. They talk about experiences of clients who have bad experiences about this. And I will say one thing, for clients to give feedback is hard. I don't know about you, Spencer, but it's hard for clients to tell. And if you have a high temperament for agreeableness, that's hard to say something that may be going to be creating some tension in the room. But I think figuring out some ways to vocalize that is important. Now, this is why if therapists have a structure where they're measuring outcomes and alliances, this gives them a little bit of a scaffold, a bit of a safety net to catch those things as well, those things that are less spoken about, because it's critical of what's going on in sight for the clients. And if things don't really match up, it's very important to kind of bring that forward. And maybe, parallel to the fact that it's hard for you to say, maybe that's also a kind of practice you need to be able just to bring that up and not to be avoiding the heat of conflict that you might do outside of therapy as well. That may be a form of practice, too. But yes, I do think it is important because without that piece, therapists are blind.

SPENCER: So final question for you. Suppose a friend is going through a really difficult mental health challenge — depression and anxiety, something like that — what can you do to help a friend? Obviously, you can't be their therapist; that's a different role. But, what can you kind of bring into that relationship with a friend based on all your experience?

DARYL: Giving space for somebody to talk through some things and to be not evading and neither invading is really critical to be able to say, "Hey, I want to hang out with you. Let's go for coffee, and let's talk through this thing." And remember, you're coming from the role of a friend. And depending on your existing level of friendship with that person at that time, it would determine how you engage. But I would argue that you can be therapeutic without being a therapist. And we would say things like, "You just need to listen attentively. You just need to ask questions." I think those things are true, but we also want to listen carefully to, as I mentioned earlier, you could think about this in a framework about what they will say, what they won't say, what they can't say, what's difficult, and to listen carefully to those things that's happening on the inside, not just things happening on the outside in their life, but the inner life: What are they experiencing? What's the biggest pain point that they are going through? What do they need as a friend? And again, depending on the level of friendship that you might have with that particular person, sometimes you could just speak your mind and say, "Hey, I'm thinking about it from this viewpoint. This is just my view." You could just shoot that way because you may have the license to do that. Early on, you mentioned an example but given a different perspective. Sometimes you may have to say, "Can we see it this way?" And that might be helpful or it may not be helpful. If it's not helpful, drop it. But I think creating a sort of space of friendship, of connection, is really critical. Because the paradox is this: We don't come together in our communities, in our friendship circles, because of our strengths. We come together in times of weakness because that's where we seem to bind, that's where we seem to forge good relationships. I'm thinking about a friend who is struggling right now as well. Strangely enough, because of her circumstance, the friendships that go around, we are coming together to be with her. We're coming together to see if we can lend support to her and her family as well. And I think that's the paradox of our human nature.

SPENCER: Daryl, thanks so much for coming on.

DARYL: Thanks! You asked really precise questions. I love it. Thank you so much.

[outro]

JOSH: A listener asks: Do you think there are any real sustainable solutions to end human trafficking?

SPENCER: I think there are a few different types of human trafficking that are worth separating out in order to analyze something like this. So one type of human trafficking is labor trafficking, where people are brought from one country to another in order to engage in, often, illegal work. So let's keep separate this from sex work because I think it is a whole other category. But let's just say illegal immigration to do work. For example, farming work or other kinds of work, such as manual labor. I think this category is a very complicated one, because there could be situations where the worker wants to move to another country and engage in work there. But once they get there, they may regret it or the treatment of them might be far from ideal. And also, they might be violating the law by being there. So there's a lot of complicated issues here. But in many ways, this kind of issue may look like other kinds of potentially illegal immigration. And so, sort of analysis might be similar for how you treat other kinds of illegal immigration. However, a fundamental difference might be that people who are in this kind of situation may not feel empowered if they're being mistreated. So if they're being treated really badly, they might not feel that they could go to the authorities. And so I think one way to help with this kind of situation is to have a separation of, "Okay, some people might be in your country illegally, but they should still be able to report a crime, or they should still be able to report something bad happening without being punished." Because I think it just creates a really bad incentive if they can't report abuses just because they're there illegally. Now, if you think about sex trafficking, I would split that into at least two different categories. One is child sex trafficking, like if someone is trafficking 12-year-olds and having them have sex with people. That is a very cut and dry kind of crime, where it's just very, very clear that whoever is involved in that is doing something really morally reprehensible. And also, that the child cannot consent to do that. There's also obviously adult sex trafficking, where most often women are trafficked across borders to engage in various forms of sexual activity. And there, it gets a bit more complicated because, again, you could have scenarios where some of the women do it willingly or actually know what they're getting themselves into. Whereas, others might think that they're going there for some other job and then kind of get coerced or pushed into doing sexual labor. And so, I think separating out the cases of people doing it willingly, but it may be doing it illegally, versus people who are really doing it against their will. And there, I would again emphasize the importance of allowing people to report things even if they're breaking the law. So let's say a woman is doing illegal sex work, it's very, very important that they still be able to report to the police the abuses that are occurring without being punished just because they're themselves breaking the law, because that creates, again, a horrible incentive. So these are really hard problems to solve, but those are just a few thoughts about it.