Live at EA Global - The future of U.S. foreign aid (with Dean Karlan)
Dean Karlan discusses rebuilding foreign aid with evidence-based strategies and empowering partner governments. The episode also explores effective therapy, particularly CBT and DBT, for emotional regulation, interpersonal skills, and balancing acceptance with change.
Deep Dive Analysis
22 Topic Outline
Therapy Quality and Evidence-Based Practices
Critique of Therapists Listing Many Approaches
Common Factors vs. Specific Therapeutic Tools
Effectiveness of Manualized Treatments in Therapy
Core Components of Effective Cognitive Behavioral Therapy
CBT vs. Medication for Depression and Anxiety
Side Effects and Long-Term Impact of Therapy and Medication
Introduction to Dialectical Behavioral Therapy (DBT)
DBT's Focus on Emotion Dysregulation and Skills Deficits
Broad Applications of DBT Beyond Borderline Personality Disorder
Challenges and Support for Therapists Treating BPD
Dialectics in DBT: Non-Judgmental Thinking and Fact-Checking
Understanding and Applying Radical Acceptance
Validation in Interpersonal Relationships and Self-Validation
Balancing Acceptance and Change in Daily Life
Resources for Learning DBT Skills
Priorities for Rebuilding USAID 2.0
Political Interference and Misinformation in Foreign Aid
Decision-Making in Aid Without Complete Evidence
Strategies to Improve and Influence Foreign Aid Policies
Future of US Foreign Aid: Transactional vs. Relational Approaches
Seizing the Opportunity to Redesign Foreign Aid
11 Key Concepts
Common Factors (in therapy)
Elements present across different therapies, such as the therapeutic alliance (relationship between therapist and client), warmth, support, validation, and empathy. These are considered foundational for effective treatment, especially for less severe problems.
Dodo Bird Hypothesis
The idea that all types of therapy work equally well, suggesting that the specific therapeutic approach doesn't matter as much as common factors or therapist attributes. The episode suggests this hypothesis has been largely disproven by studies on manualized treatments.
Manualized Treatments
Standardized therapeutic approaches with clear, written protocols (like a book) that guide the therapist. These treatments have been studied for effectiveness and are based on psychological science, offering a structured yet flexible framework for addressing specific mental health problems.
Cognitive Behavioral Therapy (CBT)
A type of therapy that helps people evaluate and change their interpretations or thoughts about situations to affect how they feel. It often involves "homework" and focuses on clear, agreed-upon goals to facilitate comprehensive changes.
Dialectical Behavioral Therapy (DBT)
A form of CBT developed by Marsha Linehan, initially for suicidal individuals with borderline personality disorder. It integrates traditional CBT's focus on change with an emphasis on acceptance, striving for a "dialectical balance" between changing what can be changed and accepting what cannot.
Emotion Dysregulation
A core assumption in DBT, referring to experiencing strong emotions that feel out of control, leading to problems in behavior (e.g., lashing out, substance use) or general misery. DBT aims to address this by teaching skills to manage emotions.
Skills Deficit Model (DBT)
The assumption that many mental health problems stem from a lack of learned skills to respond differently to situations or emotions. DBT's approach is to teach people these missing skills, making it widely applicable beyond its original target population.
Dialectical Balance (DBT)
The core principle in DBT of holding two seemingly contradictory truths simultaneously, such as the need for both change and acceptance. It encourages non-judgmental thinking and recognizing that situations are often more complex than black-and-white interpretations.
Radical Acceptance
A DBT skill involving completely and totally accepting a moment or situation exactly as it is, recognizing that it could not be any other way. It helps reduce suffering, which is pain plus non-acceptance, by letting go of the struggle against reality.
Validation
A DBT interpersonal skill that involves communicating understanding and acknowledgment of another person's (or one's own) thoughts, feelings, and behaviors. It helps foster connection and effectiveness in interactions by making the other person feel understood, and for oneself, it leads to self-compassion.
Cost-effectiveness Thinking (Foreign Aid)
An approach to decision-making in foreign aid, especially when evidence is scarce. It involves mapping out a theory of change, breaking down the chain of events into steps, and making "back-of-the-envelope" estimates for each step to reality-test whether an intervention seems like a good idea.
15 Questions Answered
Not necessarily. It could be a problem with the match between the client and therapist, or the quality and type of therapy being delivered, as many people may not receive quality, evidence-based treatment.
Specializing in one approach is generally preferred because different therapies often have conflicting worldviews, making it difficult to achieve comprehensive change when a therapist is too scattered across many different methods.
Common factors include the therapeutic alliance, listening, validation, and empathy. They are a crucial foundation, and for some with less severe difficulties, they might be sufficient, but for greater mental health problems, specific evidence-based treatments are often necessary.
The dodo bird hypothesis suggests that all therapies work equally well, implying the specific type of therapy doesn't matter. However, enough studies have emerged to suggest that manualized, evidence-based treatments are generally more effective than non-specific therapies.
Cognitive Behavioral Therapy (CBT) is the most studied and has consistently shown to outperform non-specific therapy for mild to moderate cases of depression and anxiety.
Medication can be easier and effective while being taken, but its effects often cease when stopped. Therapy teaches tools and behavioral changes that are presumed to be longer-lasting, making it a good option for sustained improvement.
DBT is a form of CBT that adds a strong emphasis on acceptance to CBT's focus on change. It was developed for severe problems like borderline personality disorder, aiming for a "dialectical balance" between accepting reality and working to change it.
DBT's core assumptions—that problems stem from emotion dysregulation and skills deficits—make its techniques widely applicable. It teaches skills for managing strong emotions and responding differently to challenges, which can benefit most people.
It means recognizing and holding two seemingly contradictory truths simultaneously, such as accepting a situation while also striving to change what can be changed. This approach helps avoid getting stuck in misery by addressing both what is and what could be.
Radical acceptance is completely accepting a moment or situation exactly as it is, acknowledging that it could not be otherwise. It reduces suffering by preventing the "second arrow" of pain that comes from resisting or ruminating on what cannot be changed.
Validation involves communicating understanding and acknowledgment of another person's (or one's own) thoughts, feelings, and behaviors. In interpersonal interactions, it makes others feel understood, increasing effectiveness. For oneself, self-validation fosters self-compassion and reduces self-criticism.
Priorities include identifying and protecting a core set of commonly agreed-upon programs, embedding evidence and cost-effectiveness from the start, and centering partner governments by strengthening their capacity for service delivery and policy integration.
The shutdown was politically motivated by "MAGA dogma," with accusations based on misinformation. The speaker believes it couldn't have been prevented by making a better case, as the opposition was determined to spread falsehoods regardless of the truth.
Employ cost-effectiveness thinking: outline a theory of change, break down the process into sequential steps, and make "back-of-the-envelope" or Fermi estimates for the magnitude of impact at each step to reality-test the potential payoff.
A transactional approach, where aid is given in exchange for specific concessions (e.g., mining rights), is dangerous because it yields only what is negotiated or bullied for, failing to build healthy, long-term relationships or foster genuine development in partner countries.
23 Actionable Insights
1. Balance Acceptance & Change
Actively assess situations by asking what you can change and what you must accept, as much of everyday suffering comes from trying to change the unchangeable or failing to change what’s possible. This dialectical approach helps you get unstuck and reduce misery by effectively responding to problems.
2. Prioritize Evidence-Based Therapy
If therapy doesn’t work, don’t conclude it’s ineffective for you; instead, question if your therapist is using evidence-based approaches and has high-quality training. Many people don’t receive quality therapy, and manualized treatments are generally more effective for mental health problems.
3. Practice Radical Acceptance
Completely and totally accept the present moment or situation exactly as it is, recognizing that it could not be any other way. This reduces suffering by distinguishing it from inevitable pain, as suffering often arises from resisting reality or trying to change what cannot be controlled.
4. Validate Others Effectively
Communicate understanding and acknowledgment of another person’s thoughts, feelings, and behaviors, especially in challenging interpersonal situations. When people feel understood, they are more likely to engage in conversation and collaborate, leading to more effective outcomes.
5. Practice Self-Validation
When experiencing difficult emotions, tell yourself, ‘It makes sense that I feel this way,’ instead of using ‘should’ statements like ‘I shouldn’t be so upset.’ This fosters self-understanding and can lead to self-compassion, opening up possibilities for new perspectives.
6. Plan Difficult Conversations
Before engaging in challenging interpersonal interactions, use a structured approach like the ‘DEAR MAN’ skill to plan your communication. This preparation helps you think through how to be most effective, reduces impulsivity, and increases the likelihood of achieving your goals.
7. Embrace Dialectical Thinking
Strive to see things as more complex than just right or wrong, incorporating other aspects of what’s happening to have a non-judgmental interpretation of situations. This critical thinking skill helps you move beyond black-and-white thinking and recognize multiple truths.
8. Seek Solutions for All Problems
Adopt a problem-solving mentality, believing there are always different ways to respond to a situation, even if the core problem cannot be entirely eliminated. This empowers you to suffer less by finding healthier ways to process and react to challenges.
9. Embed Evidence in Aid Strategy
Integrate evidence and cost-effectiveness thinking from the very beginning of strategy, rather than as an afterthought in evaluation. This ensures that aid programs are based on what’s most effective for addressing problems and guides where new evidence needs to be produced.
10. Center Partner Governments in Aid
Emphasize strengthening partner governments and their delivery of services and policies in foreign aid initiatives. This approach is absolutely critical for the long-run development of countries and helps integrate learning into their own delivery processes.
11. Choose Manualized Therapy
For greater mental health problems like depression and anxiety, seek manualized treatments that have standardized protocols and have been studied for effectiveness. These treatments are generally more effective than non-specific therapy.
12. Look for CBT Homework & Goals
If pursuing Cognitive Behavioral Therapy (CBT), ensure your therapist assigns homework and works with you to establish clear goals that are consistently revisited. Homework is an integral part of CBT, and clear goals ensure focused, effective treatment.
13. Consider DBT for Emotion Control
If you struggle with strong emotions or feel a lack of control over them (emotion dysregulation), Dialectical Behavioral Therapy (DBT) may be a more suitable starting point than CBT. DBT is a skills-deficit model designed to teach people how to manage emotions and respond differently.
14. Understand Therapy’s Lasting Impact
Recognize that therapy teaches people tools to change how they behave and respond, leading to longer-lasting effects even after treatment stops. In contrast, medication effects often cease when discontinued because it doesn’t impart new skills.
15. Prioritize Bipartisan Aid Programs
When rebuilding an aid agency, identify and protect a core set of programs that have common, bipartisan agreement. This ensures continuity and support for essential initiatives, focusing on shared public interest rather than political division.
16. Seize Systemic Change Opportunities
Recognize that moments of disruption or a ‘blank slate’ offer a critical opportunity to implement long-term, evidence-based changes in large organizations or systems. Invest in systemic improvements now to have a lasting impact in the future.
17. Use Cost-Effectiveness Thinking
When evidence is lacking for big decisions, apply cost-effectiveness thinking by outlining a theory of change (a chain of events) and estimating the magnitude of each step. This provides a reality test for whether an idea is likely to pay off and guides resource allocation.
18. Fund Local Innovation in Aid
Help fund innovation and tests in partner countries to assist their governments in integrating evidence-based thinking into policy design. This strengthens local capacity and promotes effective, context-specific solutions for development.
19. Improve Evidence Synthesis
Address the gap between academic research and practical application by working hard on meta-analysis, synthesis, and mapping research lessons to actual procurement needs. This ensures that the vast amount of evidence produced effectively informs and improves aid programs.
20. Avoid “Expert-in-Everything” Therapists
Be cautious of therapists who list many different types of therapies, especially those with conflicting approaches like cognitive behavioral and psychoanalytic therapy. This can be a red flag, suggesting a scattered approach that may not lead to effective, comprehensive change.
21. Recognize Therapy’s Common Factors
Understand that empathy, listening, validation, and a strong therapeutic alliance (the relationship between therapist and client) are common factors necessary for therapy to be helpful. These form a foundation, though more severe problems often require specific, manualized treatments.
22. Be Aware of Therapy’s Challenges
Recognize that therapy can bring up painful memories, experiences, or shame, and engaging in new behaviors is a challenging, non-linear process. These ‘side effects’ are an inherent part of the therapeutic journey towards change and growth.
23. Avoid Transactional Foreign Aid
Do not approach foreign aid in a purely transactional way, such as exchanging aid for mining rights, as this undermines the relationship with partner countries. Such an approach yields only what is negotiated and is detrimental to long-term development.
8 Key Quotes
Many of these therapies have different worldviews that inform them and if you are using strategies from a variety of different approaches you are not consistently following a specific worldview and in my mind that means it's going to be really hard to make comprehensive changes and help the person reach their goals effectively.
Shereen
The effects of medication only last while you're taking the medication... therapy teaches people tools to change how they behave and respond and those would in essence be longer lasting because even when they stop therapy it's presumed that you still have the tools and the new behavior available to you.
Shereen
One of the assumptions in DBT is that you haven't caused all of your problems but you're the one who has to solve them.
Shereen
Pain is inevitable. Pain is a part of life. We're all going to feel pain and actually a lot of the problems we experience is when we try to escape pain because we often try to escape pain in pretty ineffective ways.
Shereen
Non-acceptance is often the rejection of reality, right? And so once we can actually accept reality for what it is, then we will have a reduction in suffering.
Shereen
It makes sense that I feel this way because when you experience criticism, it's painful, right? Or it makes sense that I feel this way because I experienced a lot of criticism as a child and I never learned how to cope with it.
Shereen
I didn't meet a single person in USAID that... opening statement was, 'Welcome, well, I don't understand why did you join? We're the most amazing efficient organization on this planet. There's nothing to change here. This is, we're perfect.' Everybody was passionate about helping other people.
Dean Karlan
It's like literally imagine having a marriage in which every single thing you did for your spouse was contracted and negotiated. That's not a healthy marriage.
Dean Karlan
1 Protocols
Dear Man Skill (DBT Interpersonal Effectiveness)
Shereen- Describe the situation clearly.
- Express how you feel about it.
- Assert specifically what you want from the person (ask for something or say no).
- Reinforce by explaining the reward or appreciation that would result if you get what you're looking for.