A recent review by the American Psychiatric Association (APA) found that there are currently over 10,000 mental health apps on the market today.
At first glance, that number is astounding. However, technology in mental health is not necessarily a new concept. The 1966 advent of the Rogerian artificial intelligence therapist named Eliza marked the first formal introduction of technology being applied to mental health in general, and to the process of therapy in particular. Although the limited technology that built Eliza was far from making a meaningful contribution to the course of mental healthcare in America, it nonetheless represented an important milestone that has since snowballed into our current ecosystem of mental health applications used by billions of people worldwide.
While there are all kinds of mental health-related applications that service a wide range of functions, most of which are of the “self-serve” type, what has drawn my attention most are those that are used to supplement or enhance my own work as a therapist. Truth be told, my skepticism around the prevalent use of self-serve apps - particularly those with largely unfounded clinical outcome claims about producing a quick fix for [insert any diagnosis here] - has limited my interest in recommending these apps as an alternative to face-to-face therapy. However, technological innovation in the context of supporting, rather than replacing, the work that we do in therapy has piqued my interest for quite some time.
In this context, I have found that technology used to enhance the therapeutic process can be clustered into three overarching domains, which are detailed in brief below.
1. Technology for improving access to care.
It’s no surprise that the largest impact that technology has had on the mental health and wellbeing of individuals across our world is the advent of online telehealth platforms. Individuals who previously were denied care due to a lack of access to qualified health professionals (e.g., those in rural areas, with disabilities, or with limited resources for transportation) can now access quality care in a matter of minutes. Telehealth companies such as Regroup and Ginger are changing the way in which we understand the therapeutic relationship, and the process of therapy more generally, through the addition of a computer screen separating therapist and client. Although there are certainly a number of noteworthy factors that warrant consideration with regard to providing telehealth services (client safety, confidentiality, and boundaries come to mind), even the technology-wary therapist has a hard time arguing against the profound benefits that come from increasing access to care for those who need it.
2. Technology for screening, assessment, and risk management
Leaders in our field have advocated for measurement-based care for decades, and countless research studies have confirmed that integrating routine screening and outcome monitoring into your practice in one way or another significantly improves your ability to detect client deterioration, make appropriate referrals, and make better treatment decisions throughout the course of therapy, among others benefits. However, the implementation of measurement into practice has traditionally been halted by the cumbersome process of collecting relevant information and - quite frankly - the annoyance that inevitably arise when administering and making sense of paper-pencil assessments during your sessions. As a result, less than 20% of clinicians practice measurement-based care to date. Luckily, technological advances are solving these issues by making it as easy as ever to routinely screen and assess client symptoms and progress in therapy. For example, companies such as Blueprint allow therapists to assign rating scales and screeners for clients to complete on their own time while at home. These platforms can alert you when a client’s data shows a spike in severity and can even link the client to local crisis resources for just-in-time interventions. Although seemingly simple, these advances can make a world of difference when trying to integrate measurement and screening into your otherwise busy clinical practice.
3. Technology as an adjunct intervention
The research around combining app-based interventions with face-to-face therapy tells a similar story to what is commonly found in outcome studies for psychotropic medication and therapy: they work alone but are better together. Many mental health apps are specifically designed to serve as a supplement to individual therapy by focusing on aspects of care that you want your clients to be doing anyway - such as learning new skills and practicing techniques outside of the therapy office. In fact, simply monitoring thoughts and emotions daily, which represents a fundamental component of cognitive behavior therapy (CBT), has been identified as a leading predictor of early positive change in CBT for depression and anxiety. It’s no surprise that self-monitoring apps are also among the most downloaded mental health related apps on the market today. As therapist, we should be encouraging our clients to partake in this type of behavior as a means of engaging more fully in the process of therapy and generalizing skills outside the therapy office.
A Lesson Learned
For some of you, the addition of the three domains of technology into your practice mentioned above comes naturally. For others (myself included) it does not. In fact, throughout my early years of clinical training I was vehemently opposed to introducing technology and apps into my clinical work. The foundation of my focus was (and still is) all about cultivating the therapeutic relationship, and together with my burgeoning passion for helping clients build a contemplative/meditative practice into their daily lives, I just couldn’t fathom why I would ever want to pull up a computer screen or bring out my cell phone during a session.
However, it wasn’t until my clinical training with Hasbro Children’s Hospital & Alpert Medical School at Brown University that the integration of technology into quality mental healthcare was de-mystified. The psychologists I worked under had a wonderful approach to implementing the three domains of technology mentioned above in a non-invasive and rapport-strengthening manner, and in a way that enhanced the therapeutic work that was being done. In this light, I’ll share one small excerpt from this experience in the form of a case study in order to illustrate how technology can be integrated into your clinical practice to support your work and improve your clients’ mental health and wellbeing. Please note that all identifiable information and certain aspects of the case report have been modified for privacy purposes.
Katie was a 16-year-old female who was referred to me due to PTSD symptoms following a traumatic experience with a family member. She initially presented as cautious, with flat affect, and with little ability for back and forth conversation. Given her presenting symptoms and overall demeanor, I used a trauma-focused cognitive-behavior therapy (TF-CBT) approach to help her overcome her distressing internal experiences that were holding her back from engaging fully in her academic, home, and social life.
Following a few weeks of psychoeducation and building rapport, we started working on relaxation and grounding skills to help her reduce the panic and hyper-arousal that she would experience in the face of trauma-related triggers at school and with friends. Although she would engage in exercises during our sessions, she had difficulty maintaining this practice outside the office. After reviewing several relaxation apps, we collaboratively identified the app “Stop Breathe and Think” to support her independent practice of these skills. Katie found this app extremely helpful, particularly around a feature to support paced breathing, as well as a daily journal function for her to express her thoughts and feelings in the moment. Moreover, she enjoyed bringing up the journal entries during our sessions as a means of communicating significant events that occurred over the week with more detail than if she relied on recall.
Over the course of six months, she became increasingly able to manage her symptoms of PTSD and felt as though she was finally beginning to take back control of her life. However, an upcoming out-of-state move with her parents required that we make a decision regarding the remainder of her care. I felt as though she still required the support and assistant of a therapist, and yet had progressed enough to warrant holding off on transferring to a new therapist for continued care. As such, we decided on using a telehealth platform to continue having sessions virtually on a bi-weekly basis with the goal of ending services within the year.
Given that I would no longer be meeting with Katie face-to-face, I decided to implement a remote assessment and screening platform as an additional precaution for keeping an eye on Katie’s health and wellness as she adjusted to the move. Katie was assigned the Patient Health Questionnaire Adolescent (PHQ-A) and the Trauma Symptom Checklist Short Form (TSCC-SF) to complete through the mobile app on her phone on a bi-weekly. I would review the results with Katie during our sessions and bring up any noteworthy changes to her functioning for further discussion.
Six weeks into her move, I met with Katie through the telehealth platform as usual and things seemed to be going just fine. She was keeping up with her journal entries in the Stop Breathe and Think app, which we would use as an additional source of communication. However, when reviewing her most recent assessment, I noticed that Katie reported “sometimes” to the suicide-related question on the PHQ-9. When asked about this response, Katie reported that she had been feeling “a little off lately” and that she had been experiencing suicidal thoughts that were like her experiences early on in our time together. Upon further inquiry and discussion, Katie and I jointly decided to make a referral to a trauma specialty clinic in the area that could better assess safety and set her up for a longer course of care with a local therapist. Katie and I had one final session before her transition to the new therapist, and at that time she was feeling hopeful and optimistic for positive change. Although Katie’s case doesn’t have a resolution for our story today, I hope that it is a helpful example of the way in which technology can be integrated into clinical practice to support the process of therapy across the care continuum.
Looking Back, Looking Forward
While the list of mental health apps entering the market is growing each day, the practice of psychotherapy is, and always will be, founded upon the uniquely human relationship that occurs between a therapist and a client – something that technology in and of itself cannot reproduce. As a result, it is our responsibility as therapists to adjust to this new culture and learn how to integrate these tools into our practice, while also being mindful of the limitations that technology may have in supporting our work.
For example, a primary area of interest in contemporary mental health app development is the ability to detect psychological disorders or pathological behaviors using complex data analytic techniques such as machine learning and artificial intelligence. Doing so would, in theory, enable better prevention through linking individuals to healthcare services earlier in the disorder progression, and would help therapists identify clients at risk for relapse before they exhibit observable symptoms or behaviors. However, despite this type of technology currently being available on the market, such innovation is far from obtaining widespread research support and validation. As a result, clients may be vulnerable to the effects of misinformation (e.g., a client who is wrongly identified with a particular mental health disorder), and clinicians need to increasingly trust their clinical judgement amongst potentially opposing information from unvalidated sources.
In summary, technology can and should have a place in the therapy office. In particular, therapists should take notice of technology that increases client access to care, assists in screening and routine assessment, or can be used as an adjunctive intervention to support your face-to-face therapy sessions. My own experience has taught me that cultivating a sense of curiosity and willingness for change, together with a healthy sense of skepticism, is the best approach to jump-starting a technology-friendly practice. I’m hopeful that you all can get out of your comfort zone and do the same.