Monday, June 22, 2015

Psychotherapy: Now There's an App for That

The good news is: they are not outsourcing your job to Bengalore.

The bad news is: they are replacing you with an app.

If you are a psychotherapist-- especially one who practices cognitive-behavioral therapy (CBT)--that’s today’s news.

For those therapists who do not practice CBT, the news is not much better. The more studies there are, the more we see that CBT does the best at helping people with a variety of psychological conditions.

And yet, researchers have discovered that the same treatment can be provided by an app. It’s called online CBT. You can download it onto your iPad and work away at reprogramming your mind and mitigating the influence of those pesky negative and self-destructive thoughts.

As a consolation for therapists, studies show that it helps for a patient to check in on occasion with a coach. And they also show that for really difficult cases, a human therapist is preferable to an app.

That leaves a large number of people out there with only their app to guide them.

Tina Rosenberg reported the story in the New York Times.

First, she defines CBT:

… a cognitive behavioral therapist aims to give patients the skills to manage their moods by helping them identify unhelpful thoughts like “I’m worthless,” “I’ll always fail” or “people will always let me down.” Patients learn to analyze them and replace them with constructive thoughts that are more accurate or precise. For example, a patient could replace “I fail at everything” with “I succeed at things when I’m motivated and I try hard.” That new thought in turn changes feelings and behaviors.

As I have often had occasion to point out, this form of therapy has produced excellent clinical results. The new studies have shown that online CBT works just as well in most cases.

Rosenberg explains:

The success of cognitive behavioral therapy is well known; many people consider it the most effective therapy for depression. What is not widely known, at least in the United States, is that you don’t need a therapist to do it. Scores of studies have found that online C.B.T. works as well as conventional face-to-face cognitive behavioral therapy – as long a there is occasional human support or coaching. “For common mental disorders like anxiety and depression, there is no evidence Internet-based treatment is less effective than face-to-face therapy,” said Pim Cuijpers, professor of clinical psychology at the Vrije Universiteit Amsterdam and a leading researcher on computer C.B.T.

Of course, the app is especially helpful for people who do not have access to a real therapist, for reasons that have to do with time or money or location:

Depression is the leading cause of disability for women worldwide, and the second-leading cause for men. If medical care is hard to come by in much of the world — in rural Indiana as well as rural India — mental health care is often impossible to get. In the United States, at least half of major depression goes untreated, and in very poor countries the figure is close to 100 percent.


Online therapy can’t do much about those barriers. But it can help people who stay sick because there are no therapists nearby, who fear being judged or embarrassed in therapy, who can’t take time off from work, or for whom the cost of treatment is too high. It allows people to carry therapy around in their pockets, use it at 2 a.m., and pay nothing or nearly nothing.

How effective is it?

Rosenberg answers:

A Swedish survey of studies found that online C.B.T. has been tested for 25 different ones. It was most effective for depression, anxiety disorders, severe health anxiety, irritable bowel syndrome, female sexual dysfunction, eating disorders, cannabis use and pathological gambling. “Comparison to conventional C.B.T. showed that [online] C.B.T. produces equivalent effects,” the researchers concluded.

Obviously, there are limits:

Cuijpers said there were fewer studies of online therapy to treat insomnia, pain and alcohol abuse, but what’s been done has shown good effects. (Last week the Upshot published one contributor’s story of his success using online C.B.T. for insomnia.)

Though, in some cases, human support or coaching is necessary:

One study of adolescents found that almost 60 percent of users stopped MoodGYM after the first module when they were working unsupported on their own. When the same program was used with monitoring and support, only 10 percent stopped.

Obviously, therapists see it as a threat to their practices:

The reception for online cognitive behavioral therapy isn’t uniformly warm — and the dissenters are not just therapists worried about being put out of business (if only untreated depression were that scarce a commodity). One big issue is that someone seriously ill might waste time tootling around with an online program, not realizing he needs more help. Or he might use a program that isn’t right for him. It’s safer, of course, if a therapist sees the patient and then prescribes online therapy. That’s an efficient use of therapists — but it still requires a therapist, and that negates some of online C.B.T.’s advantages.

[Addendum: Thanks to commenter TL for providing this link to a recent study of treating cocaine addiction with CBT.]


Anonymous said...

Actually, the evidence shows that CBT is effective only for the short-term, almost useless in the absence of an actual human relationship, and diminishing in its returns over the past 40 years. But. if you put your faith in a CBT app to teach you how to reason, go right ahead. The results couldn't be worse than this gullible post.

Stuart Schneiderman said...

It would be a nice idea to share your evidence. Rosenberg and many, many others have provided a great deal of evidence to support their viewpoint. It has become more and more available as therapists have documented its value... and as I mentioned in my book studies show that one or another variety of CBT is among the best treatments for autism. One might mention that psychoanalysis, as practiced by Freud and Freudians does not allow for a human relationship.

Anonymous said...

Well, for starters, CBT losing its effectiveness:

No long-term benefit for online CBT:

I assume you're proficient at google, and can therefore find plenty of other critiques of CBT yourself, as well as evidence underpinning the common factors approach, which highlights why apps might make poor therapists. There is growing empirical evidence for psychoanalysis, from Fonagy, in the UK, for instance, as well as a number of researchers from Belgium and elsewhere. Somehow, though, I suspect your objection to psychoanalysis is not really about empirical data.

In any case, have you read Beck? Ellis? Their doctrine is little more than suggestion. It's authoritarian garbage, and the sort of philosophically naive coaching on positivity more appropriate to China (circa the Cultural Revolution) than a contemporary democracy. It's a cheap and shoddy product, perfect for insurance companies and bureaucrats, but not something any therapy-literate person would use.

Stuart Schneiderman said...

Oh my, apparently all of that psychoanalysis has not done very much for your foul temper and bad mood. Sorry to hear it. I have addressed many of these issues in my last book, among them the question of the empirical basis for psychoanalysis. See Edward Erwin's book: A Final Accounting. Obviously, hope die hard, but psychoanalysis has pretty much died out by now... except perhaps in France and Argentina. It did not die out because it's effective. It died out because, as Freud and Lacan both agreed, it is not clinically effective. Lacan said that it was a scam, but I have discussed that often enough in enough places, so I will not repeat myself. I also discussed the use of the placebo effect in psychoanalysis. If psychoanalysis continues to survive in France that's because they are not pretending to be curing anything. They are providing a cultural re-education, one that has been modeled on the Chinese Cultural Revolution... which continues to inspire many of them. Check out their favorite philosophers, Badiou and Zizek. Of course, the Lacanian movement is an authoritarian cult... but presumably you do not know any more about that than you know about theory. Cognitive exercises are not suggestion, but insight oriented therapy certainly is.

Anonymous said...

LOL. You address none of the CBT points, but prefer a deranged rant against your ex, psychoanalysis. Badiou and Zizek are not analysts, by the way. Instead, in shilling for CBT, you're advocating for reason to be adapted to what is "helpful" to the reasoner. Sounds a lot like relativism, narcissism, and moral cowardice.

Stuart Schneiderman said...

Speaking of deranged rants... ever heard of projective identification? Glad that you have graduated to the level of name calling, but you have still not said anything coherent. I have addressed the theoretical basis of CBT in my book-- and of course I do not practice it. You are right about one thing... Badiou and Zizek are not analysts, but they are constantly being published in Lacanian Ink, a psychoanalytic journal. Surely, they support the field. One might note that true Lacanians have been forbidden to read me, and, if they were in Paris, were told that they should not read my first book on Lacan.

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