Rachael Ann Polokoff, M.S. Pre-Doctoral Psychology Intern

Theresa Ratti, Ph.D., Supervising Psychologist

The Role of Computerized & Mobile

Technology in Therapy: Evidence Base,

Ethics, Limitations & Future Directions

Speaker Disclosure: The following speakers and/or

their spouse/partner have reported no relevant

financial relationship with a commercial interest:

•Rachael Polokoff, M.S.

•Theresa Ratti, Ph.D.

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Opening Discussion Question:

How many of you already use

technology in your practice?

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“Her” (2013)

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Overview of Presentation

(1) Telepsychology: Definitions and Rationale

(2) Examples of New Technology Uses in Therapy

(3) Evidence Base

(5) Ethics of Telepsychology

(6) Limitations

(7) Future Directions

(8) Discussion Groups/Case Vignette

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Key Definitions and Terms

• Important due to fact that literature often uses

terms interchangeably.

• Difficult to have a common language when

technology evolves so fast.

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Telepsychology: Definitions

(APA, 2013)

• “Telepsychology”: the provision of psychological

services using telecommunication technologies.

• Often used synonymously with “teletherapy.”

• Include but are not limited to: telephone, mobile

devices, interactive videoconferencing, email, chat,

text and Internet (self-help websites, blogs, and

social media).

• May augment traditional in-person services or be

used as stand-alone services.

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More Definitions: (APA, 2013)

• “Remote”: the provision of a service that is received at a different site than the therapist is located.

• “Jurisdictions”: governing bodies of states, nations, or provinces.

• “Confidentiality”: data or information is not disclosed to unauthorized persons.

• “Security measures”: terms that encompass all of administrative, physical and technical safeguards.

• “Information system”: interconnected set of information resources within a system.

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Other Terms Used in the Literature

• “apps”: smartphone applications

• “CCBT”: computerized cognitive behavioral

therapy (Grist & Cavanagh, 2013)

• “mHealth”: mobile health (WHO, 2011)

• “SMS”: short message service or “text messaging” (Wagner, Hospital, Morris & Sawant, 2014)

• “TAP”: Technology-aided psychotherapy (Delucia,

Harold & Tang, 2013)

• “T2”: National Center for Telehealth & Technology

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Telepsychology: Rationale

• With the use of new technology, psychologists can:

– Attract new patients/clients

– Provide services where previously unavailable

– Perform therapy

– Assist in suicide prevention

– Increase clients’ coping skills

– Increase therapeutic alliance and

communication (Overholser, 2013).

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Rationale (continued)

• Teletherapy mobile apps and computer programs are

being developed and used at a fast rate.

• Often developed without significant effectiveness data.

• More than 200 unique mobile phone apps specifically

for behavioral health (Luxton et al, 2011).

• As consumer demand increases, it is essential that

therapists educate ourselves on new technology, and

continue to research efficacy and effectiveness.

• It will likely be increasingly used with or without our

professional input.

• Should we get “left behind” as a field?

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Client/Patient Use of New

Technologies No meta-analyses exist yet that pin down

demographic of users but:

•3.8 million podcasts from thepsychfiles.com

downloaded worldwide (Luxton et al, 2011) .

•“PTSD Coach” app downloaded 135,000 times in 78

countries (Hoffman & Weingardt , 2014) .

•Over one billion subscribers to high speed mobile

connections (Gaggioli & Riva 2013) .

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Practitioner Use of New Technologies

•Very few studies about the use of teletherapy in

practice today.

•9.8% of responding practitioners for a national

study use weekly email for clinical services (Jacobsen

& Kahout, 2010)

•Epocrates app is used by more than one million

health care providers in the U.S. (Luxton et al, 2011).

•Iris used by Forrest General Hospital and

Hattiesburg Clinic.

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Example of New Technology : Computerized

Cognitive Behavioral Therapy (CCBT)

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CCBT

• Any form of CBT that is delivered via an interactive computer interface, (offline computer program, or internet).

• Delivery of an effective evidenced based treatment may offer potential benefits:

-increased availability

-increased reach

-cost-effective treatment

-less stigma and no requirement to take off work

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Coping with Craving Program (Kathleen Carroll and Yale University, 2013)

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“Beating the Blues”

CCBT for Depression (Proudfoot, 2013).

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Beating the Blues (Proudfoot, 2013)

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Example of New Technology: Mobile

App Therapy

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Different types of Apps:

• Self monitoring apps

• Relaxation apps

• Automated therapy apps

• Mood and memory apps

• CBT apps

• Symptom control apps

• Psychoeducation

• Suicide Prevention

• & More (see Luxton et al, 2011 for a comprehensive list )

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Advantages of Mobile Mental Health Apps

• Treatment accessibility

• Real time behavior and mood

monitoring

• Increased participation engagement in

treatment

• Real time support and motivation

• Emotional & behavioral self-awareness

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Disorders in Which Apps Have Been

Utilized

• Bulimia Nervosa • Depression • Stress • Anxiety • Smoking Cessation • Borderline Personality • Substance Abuse • PTSD • Sleep Disorders

(Luxton et al, 2011)

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Some Apps available now • iQuit

• iBreathe

• eCBTMood

• DBT Diary Card and Skills

Coach

• promises

• Recovery Record

• PTSD Coach

• SleepCycle

• PE Coach

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DBT Coach

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PTSD Coach

• PTSD Coach is an app

designed to assist with

managing the symptoms

of PTSD in the moment

(Hoffman & Weingardt , 2014) .

• Developed by

Department of Veterans

Affairs’ National Center

for PTSD in collaboration

with T2.

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MyCompass

• MyCompass is an application in which

participants can self monitor moods, mood

triggers, and behavioral symptoms in real

time.

• Developed by Australian government

grants to aid more people in free

healthcare.

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MyCompass (Proudfoot, 2013)

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Mood Map

Breathing Exercise

Body Scan

Mind Scan

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“Breath Awareness” App (Saagara,

2013)

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Evidence Base for Telepsychology

As mentioned previously, there is very little

evidence base as these technologies are new.

•In a study of mental health patients,

hospitalization utilization decreased by an

average of 25% between 2006 and 2010

when telemental health services were

delivered with remote videoconferencing

(Maheu et al, 2012) .

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Evidence Base (continued)

Meta-analysis on randomized control studies

comparing CCBT to other therapies and waiting

list controls for anxiety/depression.

•CCBT more effective than both waitlist and

active control conditions.

•Effective low-intensity intervention for anxiety

and depression.

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Evidence Base: (continued)

• A preliminary analyses determined that overall

distress, self efficacy, and depression in the

participants after using MyCompass was

significantly lowered (Harrison et al., 2011).

• Participants given option of using “Mood Map”

app significantly lowered their sadness,

anxiety, and anger ratings in therapy (Morris et al.,

2010) .

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Evidence Base (continued)

• At the end of study measuring effectiveness

of “DBT Coach,” participants had a major

decrease in urges to use substances and a

decrease in emotional distress (Rizvi et al., 2011) .

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Ethical Issues in Telepsychology

(1) Possible breach in confidentiality in the

transmission of the information (Childress, 2000).

• Confidentiality could be in danger due to

availability of information (ex: patient’s family

members or friends maybe able to access an

application on a mobile device).

• Loss, theft or unauthorized access of client’s

equipment.

• The vendor of the equipment or programs could

access or distribute the information without the

client’s knowledge.

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Ethical Issues (continued)

(2) The physical separation of the patient

and therapist (Childress, 2000).

• Could lead to miscommunications

which could alter the patient’s

treatment and lower the possibility for

success.

• Could also possibly increase risk of

Self-Injurious Behavior without

accurate assessment of risk.

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Ethical Issues (continued)

(3) Concerns about therapist and patient competency (Childress, 2000).

•Therapist’s knowledge and skill in using new technologies may be limited

•The patient’s knowledge and skill may also be limited

-(Ex: Neither therapist nor patient knowing who has access to the data stored in a mobile app).

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Ethical Issues (continued)

(4) Informed Consent (Childress, 2000).

• Is the patient aware of the risks and benefits

of using new technologies?

• Is the patient aware of the comparability to

in-person services?

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What To Do?

• Guidelines in place from APA specific to

telepsychology (APA, 2013).

• However, will not apply in all situations with

all patients.

• Clinicians should use best “informed”

judgment in each situation.

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Some Ethical Practices in Telepsychology

(1) Increase Competency:

• Increase one’s awareness about new technology (CEs, guideline review etc).

• Discuss with patients the issues surrounding confidentiality and the security conditions.

• Conduct an analysis of risks to practice with the patient.

-Ex: “Is the app you are using secure and confidential?” (APA, 2013)

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Ethical Practices (continued)

(2) Utilize informed consent

• Informed consent should be in place when

using any mobile technology, whether

verbal or written.

• Policies, procedures, and safeguards

should be discussed with the patient

(Childress, 2000).

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Ethical Practices (continued)

(3) Decrease Legal Risk

• Be aware of state regulations that address

delivery of services within and between

jurisdictions and consult licensing boards

when necessary (APA, 2013).

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Jurisdiction Rules Infringement I

• Not all states have legislature surrounding

teletherapy.

• No federal guidelines either, so practicing

across state lines can be risky.

• There is not a high likelihood of litigation,

but it has happened….

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Jurisdiction Rules Infringement II

• Ex: Dr. Rosemond, psychologist licensed in North Carolina.

• Ran an advice column in a paper that was syndicated in several states, including Kentucky.

• Received complaint letter from the board saying not to practice across state lines.

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Limitations in Research

• There is a major lack of empirical evidence

on mobile applications within the mental

health field.

• Some research has been done, but most

studies include only posttest assessment

or a short-term follow-up (6 weeks).

• Most of the applications available today do

not have any research backing them.

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Limitations for Therapeutic Use

• Under an ethical obligation at most clinical

sites to use “evidence-based treatment.”

• Yet: no significant evidence base…

• In Mississippi, no telehealth statues or

regulations although the practice of psychology

includes “internet or telehealth practices.”

• Coverage mandate= must be ‘real-time

consultation” (audio-only telephone, fax or

email excluded).

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Future Directions in

Telepsychology

• More effectiveness research needed to

define what telepsychology techniques

work for whom.

• States should have specific

telehealth/telepsychology statutes to define

practice better.

• Journals specifically devoted to the study of

mobile technology would be highly useful in

dissemination of information J

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Discussion:

• Would you use apps in your practice with

the possibility of a confidentiality breach?

• How could informed consent be used with

the applications?

• Do you think the lack of physical

interaction could lead to a decline in the

treatment?

• What is your personal reasoning for not

using applications?

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Discussion: Case Vignette

• A 47- year old Caucasian female with a history of

depression and borderline personality disorder

presents in your office. She has tried Mindfulness

practice and finds it useful in session. She would

like you to recommend a DBT app on her phone to

help her in daily mindfulness practice. She has had

boundary issues with the internet in the past,

including chat rooms and cybersex. She also has

difficulty maintaining boundaries with privacy and

personal information. What do you do?

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Acknowledgements

• Taylor Nocera, B.A., for her literature review

and slide design.

• Stephen Haynes, Ph.D. for his guidance on

programming phone applications.

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References Childress, C. A. (2000). Ethical issues in providing online psychotherapeutic interventions.

Journal of Medical Internet Research, 2(1). Delucia, P., Harold, S. & Tang, Y. (2013). Innovations in Technology-Aided Psychotherapy

through Human Factors/Ergonomics: Toward a Collaborative Approach. Journal of Contemporary Psychotherapy, 2(1), 615-630.

Gaggioli, A., Riva, G. (2013). From mobile mental health to mobile wellbeing: Opportunities and challenges. Stud Health Technol Inform, 184, 141-7.

Grist, R. & Cavanagh, K. (2013).Computerized Cognitive Behavioral Therapy for Common Mental Health Disorders, What Works, for Whom Under What Circumstances? A systematic review and meta-analysis. Journal of Contemporary Psychotherapy, 43(4),

Harrison, V., Proudfoot, J., Wee, P. P., Parker, G., Pavlovic, D. H., & Manicavasagar, V. (2011). Mobile mental health: Review of the emerging field and proof of concept study. Journal of mental health, 20(6), 509-524.

Hoffman, J. & Weingardt, K. (2014). Is there an app for that? A consumer’s guide to tackling the invisible wounds of war using mobile apps and online technology. National Center for PTSD, webinar, March 2014. http://www.ptsd.va.gov

Kuhn, E., Greene, C., Hoffman, J., Nguyen, T., Wald, L & Schmidt, (2014). A preliminary evaluation of PTSD Coach, a smartphone app for posttraumatic stress symptoms. Military medicine, 179 (1), 12-18. doi:10.7205/MILMED-D-13-00271.

© 2013 Pine Grove

References

Luxton, D.,, McCann, R., Bush, N., Mishkind, M. &, Reger, G. (2011). mHealth for Mental Health: Integrating Smartphone Technology in Behavioral Healthcare. Professional Psychology: Research and Practice. 42(6), 505-512.

Morris, M. E., Kathawala, Q., Leen, T. K., Gorenstein, & E., Guilak (2010). Mobile therapy: case

study evaluations of a cell phone application for emotional self-awareness. Journal of

Medical Internet Research, 12(2), 205-212.

Overholser, J. Technology Assisted Psychotherapy (TAP): Adapting Computerized

Treatments into Traditional Psychotherapy for Depression (2013) J. Contemporary

Psychotherapy, 43(4) 235-252.

Rizvi, S., Dimmeff, L., Skutch, J., Carroll, D., & Linehan, M. (2011). A Pilot Study of the DBT

Coach: An Interactive Mobile Phone Application for Individuals With Borderline

Personality Disorder and Substance Use Disorder. Behavior Therapy, 42(4), 313-315.

World Health Organization, mHealth: New Horizons for Health Through Mobile

Technologies, Global Observatory for eHealth Series, 3, (2011), Retrieved from:

http://www.who.int/goe/publications/goe_mhealth_web.pdf, accessed October, 2013.