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Use of Technology in Mental Health

By Danielle Vasserman, Ed.M., Psy.D., William James College, Newton, MA

Technology is a significant and even imperative part of daily life for most people. Computers, phones, tablets, and other “smart” devices have long since become mainstream and utilized across all sectors of society, all cultures and ages. These devices keep us all constantly connected to the internet and to each other, making virtually any piece of information available to us at any time. Applications or "apps" on computers and smart devices have digitized various services to make them more convenient. It often seems as though anything in life is already a ‘click’ away, and the amount of tasks that can be accomplished online seems to expands everyday. As a growing number of services are becoming available online, mental health has been gradually following suit.

Health providers from all fields have used technology professionally for years, beginning with the use of the computer for internal communication and pagers to reach doctors urgently, to now using electronic medical records and patient portals which can create ready access for patients to contact their doctor and review medical information on demand. Likewise, therapists have also utilized phone calls to conduct therapy at a distance and “check in” on their patients in between office visits, when necessary. However, as the capabilities of technology grow, the mental health field is grabbling with how to adapt. What was once thought to be successful only in a face to face, in person setting, technology is proving that mental health treatment can be effectively provided at a distance, and is now bridging large gaps in access to mental health care. Today’s technology includes apps for both computers and wireless devices that complement or supplement treatment, websites that support talk therapy in various forms, as well as various digitized manual based treatments that can, in some cases, replace the need for face-to-face treatment.

The Use of Technology in Mental Health

One of the oldest and most readily available technologies in mental health care are websites that include information, and resources. In an effort to reduce stigma and increase access to services, many of these websites now provide connections to groups, lists of mental health providers, networks of peers, blogs and other expressive outlets, as well as 24/7 crisis hotlines and chatrooms for individuals in distress. Many websites are available that address specific diagnoses, and provide objective information for someone experiencing a mental health concern, or those that are supporting them. Many websites also provide information about various diagnoses, many with self assessments, so if you are concerned about your mental health you can review information and have something to share with a loved one, potential therapist or your primary care physician. As an example, Screening for Mental Health offers a variety of screening tools, many supported by local cities and states, that are available to be taken anonymously on their website.

Some websites also offer education and handouts that provide information about how to practice therapeutic concepts and skills in between therapy sessions. For example, Calm.com is a free website and application available to iOS and Android devices that provides people experiencing stress and anxiety with guided meditations, sleep stories, guided breathing exercises, and relaxing music. There are also numerous programs that offer mindfulness education, guided-mindfulness activities, and mindfulness coaches to assist in these endeavors.

One of the ways that technology is changing mental health care is by providing access to clients that either might not feel they need to see a mental health professional, or could benefit from an intervention that would not require one, through the use of chatbots. For example, a new chatbot called Woebot is a downloadable tool that is designed to mimic real human conversation, and checks in with individuals on an intermittent and random schedule, asking them to reflect and answer about how they are doing. Research is showing that having an on demand resource to offer validation and concrete tools to get through difficult moments is helping individuals improve their mental health. For clients who may worry about being judged by sitting with someone in person, they can now access the tools and support from a completely nonjudgemental app. In addition, in utilizing such a tool, some individuals may find that they need more support than the app can provide. For an overburdened mental health system, that could mean that clients who are ambivalent or not ready for the commitment of therapy can still access support, and it also may free up appointments for clients who need in person sessions with a trained professional.

While many programs and apps address the most common mental health concerns, specifically depression and anxiety, more and more are being created that are tailored to specific diagnoses. For example, there are now many apps targeting suicide prevention and Map4Speech is one example of an app designed to improve communication between parents and their children with Autism Spectrum Disorders. PRIME is an app designed to support those individuals with Schizophrenia by connecting users, who may feel socially isolated, to peers with similar challenges and enables the option of setting goals to accomplish with peer support.

For some mental health concerns, individuals may need and benefit from more contact with their mental health providers than the traditional once a week therapy session, but often insurance coverage and clinicians' schedules are prohibitive. Apps and online programs have developed as unique ways for a therapist to "keep the conversation going" with their clients and can expedite the work being done in face to face meetings. In treating eating disorders for example, it can be very difficult for clients to keep track of the meals they had, and how they were feeling, when they are seeing their mental health provider once or twice a week. However, with the use of apps like Recovery Record, clients can interact with their therapist or nutritionist to provide real time feedback about each meal, and clinicians have data to help guide their work in meetings with their clients.

Some children and adolescents may struggle in traditional "talk therapy", and it can be difficult to integrate their natural language of play into learning and practicing skills outside of therapy. However, there are now apps being developed that give the user the experience of playing a game when they are actually practicing skills that reinforce learning in therapy. For example, the video game SPARX uses CBT to help adolescents struggling with depression in an interactive way.

Certain manual based treatments, such as cognitive behavioral therapy (CBT), have also been adapted into online programs to reinforce skills learned in therapy sessions. For example, the CBT-i Coach app, which is for individuals struggling with insomnia, acts as both an electronic diary of patients’ sleep and weaves in cognitive behavioral techniques and education.

The Stay Quit Coach is an application to supplement patients in the process of tobacco cessation treatment, and another called Quitthat, for iOS, is a tool to track and monitor progress for those struggling with addiction. Additional programs and applications exist to help track symptoms, mood, and progress in treatment for a variety of treatment needs.

Simple, anonymous “chats” have also become a popular type of technology used for mental health purposes. Such chats involve trained professionals and sometimes include therapy via the chatting platform; such types of therapy is especially popular in adolescents and teens.

“Telemental Health”

What is Telemental health?

Telemental health is the use of technology as a vehicle to provide clinical assessment and treatment at a distance. Telemental health can provide a communication medium for psychotherapy, can act as an extension of psychotherapy, and can provide a psychosocial intervention via monitoring and tracking any changes. Technological devices include but are not limited to computers, phones, and tablets and often, but not always, involve a mental health professional to provide the requested services. Services provided may include assessment and diagnosis, recommendations for treatments, psychotherapy, psychiatry and various consultations. Telemental health often includes platforms supporting video-conferencing and chat rooms, where licensed mental health providers can provide an array of different services.

Technology such as conferencing platforms life Skype and FaceTime allow for psychotherapy to occur at a distance, which is common and convenient when clients are traveling or when providers are in transition within their own practice locations. However, there are risks associated with using such platforms, such as the lack of regulations around their use as well as potential dangers to client confidentiality. Skype, FaceTime and Google Hangouts is not compliant with our HIPAA Law. Luckily, current technology does offer regulated and licensed options for such services. Telemental health is defined as “online therapy”, which typically involves a therapist or counselor providing psychological counseling and support over the internet through phone, email, video conferencing, or online chats. One of the most popular websites that offers teletherapy for a monthly subscription is Talkspace, which is accessible on any device and allows users to receive therapy from a licensed provider via video conference or instant messaging. Other HIPAA compliant platforms include thera.link, which is an online therapy service founded by therapists and a technology expert. Thera.link includes an online “waiting room” and offers capabilities for clients to schedule appointments and make payments as well. Another telemental health platform with similar capabilities is WeCounsel.com; though they require a monthly subscription. One HIPAA compliant commercial platform that allows for telepsychiatry video conferencing services and includes appointment scheduling and an electronic medical record keeping is Genoa Telepsychiatry, which offers their services to clinics and providers to utilize for patients with both private insurance, as well as Medicaid and Medicare. Online and distance learning guidelines and accreditation now also exist for those interested in becoming online therapists!

Other online programs offer “interactive therapy”, which do not require participation of a live provider and are available to the client at any time of the day. Such programs typically employ highly structured evidence-based treatments, such as cognitive behavioral therapy (CBT) and Acceptance and Commitment Therapy (ACT). For example, the Canada based Centre for Interactive Mental Health Solutions offers an 8-session online interactive program based on CBT to help those struggling with depression. The program assesses mood weekly, teaches coping skills and practice activities to reinforce them, offers resources and other helpful information, and helps to solidify learn concepts with quizzes. The Woebot is another interactive approach to telemental health. This is an application that is available 24/7 to “chat” and teach concepts of CBT. Other interactive programs have been created for those struggling with Obsessive Compulsive Disorder during episodes as well as track weekly severity levels.

Other types of platforms also exist offering a combination of different services that create a safe, holding environment for users and a more encompassing approach to telemental health overall. One such platform, Big White Wall, offers a plethora of services, from assessment, to online therapy, to anonymous peer support, to online courses, tools, and resources, an space to express oneself, and “wall guides” who are trained persons available 24/7 to assist someone in crisis.

Mobile telemental health encompass such services through wireless devices, such as phones and tablets. Mobile devices offer options like monitoring treatments and adherence to it, appointment reminders, health promotion, continuous assessment and monitoring, patient recordkeeping, and direct audio and/or video patient services.

What are the benefits?

Increased Access:

There are many benefits to telemental health services; the largest of which includes overcoming various barriers to services. For example, there are not enough mental health providers to meet the growing needs of people requiring services, which is an even greater problem in less populated, rural areas. Additionally, attending therapy regularly is often a commitment that many working families cannot make due to their busy schedules. Obtaining services digitally means greater access for such people. The same is true for those who have other physical barriers, such as disabilities or travel restrictions, for whom telemental health allows access to services that these people might otherwise be unable to obtain. Alternatively, there are those who cannot access services due to a financial limitation or lack of insurance. Offering these people free services through information or applications they can use through the internet reaches a population that might otherwise not receive treatment. Another barrier that notoriously discussed is the concept of stigma around mental health as a whole. Biases, cultural norms, and preconceived notions all contribute to reasons that people do not or cannot seek mental health services. Furthermore, the idea of sitting face-to-face with a stranger and sharing intimate secrets, concerns, and opinions is often quite intimidating to many. This is another reason many people feel they cannot seek mental health services, regardless of the stigma associated with it. Allowing people to access services and information from the comfort of their personal safe spaces and behind the safety of a device can make seeking treatment much less intimidating, especially for children, teenagers, those with social anxiety, and autism. Lastly, telemental health can offer services to populations who might have limited access due to language or cultural barriers as they often offer services in many languages.

Other Benefits:

Telemental health offers a unique potential for better fidelity to manualized treatments like CBT or DBT, which often require more strict adherence to session objectives, timelines, and assignments that is difficult to maintain in conventional therapeutic settings. Technology creates the option to better adhere to therapeutic learning and practice outside of the therapy room and in-between sessions, fostering more effective learning in this way. Additionally, therapists and psychiatrists designate a specific period of time for clients and cannot typically provide ‘check ins’ to patients or be available “on-call” as these services are not reimbursed by insurance. Some technological services have been designed to provide exactly these services to complement the actual therapeutic or prescriber office visits. Such services can offer better access to care where people are accessing more and more information; ability to build tools to meet needs in real time. 24/7 services offered via the internet allow for people in distress during odd hours of the night real help!

What are the risks associated with technology in mental health?

Though technology in mental health offers many benefits, one of the largest including increased access to mental health services, there are some caveats as well. For example, people without access to technology or the internet as well as persons who are not literate in technology, such as older populations, cannot use these services. Additionally, though few platforms do accept public insurance and some types of Blue Cross Blue Shield do include teletherapy coverage, many of the applications and online services do not accept insurance and can become very expensive for users. Additionally, some opponents of telemental health argue that internet based services do not hold people as accountable as a weekly in person meeting in terms of canceling appointments last minute and practicing techniques outside of sessions. Others argue that technology depersonalizes therapy without another human being, which defies the point of the healing characteristics of a human, in-person relationship. While this is a moot point for some, this does pose a risk concerning situations involving safety, as many services on the market are not highly regulated, HIPAA compliant, licensed programs that might allow for a prompt response to risky situations, such as abuse, self-harm, suicide, or threats to harm another. Other potential barriers to mobile telemedicine also apply to mobile mental health: network and device security, network and service availability, reliability, and efficacy of assessments and interventions, and patient adherence to mobile applications.

In Conclusion...

Is telemental health alternative or supplemental to traditional mental health care? Is technology replacing traditional talk therapy? No, but it can enhance, improve access, or ensure access for those most in need of face to face talk therapy. It also provides support when face to face support isn’t available or is not an option for someone due to significant barriers.

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Information in the article above was drawn from the following sources:

https://www.ruralhealthinfo.org/topics/telehealth

http://www.cchpca.org/md-legislation-sb-1106-teletherapy

http://www.cchpca.org/what-is-telehealth

https://www.telehealthresourcecenter.org/

http://www.mass.gov/ocabr/government/oca-agencies/dpl-lp/policy-on-dista...

http://thesource.americantelemed.org/home

https://www.bigwhitewall.com/v2/Home.aspx?ReturnUrl=%2f

https://www.washingtonpost.com/news/to-your-health/wp/2017/12/03/the-woe...

https://medium.com/@dralisondarcy/why-we-need-mental-health-chatbots-175...

http://www.latimes.com/business/technology/la-fi-thedownload-online-depr...