Apps and virtual help agents are forever changing the way psychological services are delivered
"Telehealth just makes life so much easier," says psychologist Mary Alvord, PhD, who uses HIPAA-secure video conferencing technology to see clients, conduct staff meetings and trainings, and supervise trainees as part of her practice in the Washington, D.C. suburbs. "It helps us overcome so much in terms of treatment barriers," which include stigma, access to specialists and commute times in urban areas, where "it can take 45 minutes to go just a few miles for an appointment," she says.
Now, new forms of telehealth are taking therapy beyond video conferencing. Among the latest creations is Woebot, the world's first chatbot designed to help improve mental health. Created by a team of former Stanford University psychologists and artificial intelligence experts, Woebot uses Facebook Messenger to deliver a form of cognitive behavioral therapy, asking users how they're feeling and what is going on in their lives through brief daily conversations. The bot also sends videos and mental health advice, depending on a user's mood and needs at the time.
Research shows it works. A peer-reviewed randomized controlled trial with a group of college students found that Woebot decreased symptoms of depression and anxiety after just two weeks (JMIR Mental Health, Vol. 4, No. 2, 2017).
While Woebot is certainly not intended to replace traditional psychological care, the hope is that this technology may provide a more accessible option, particularly for those with less severe mental health issues, says psychologist Alison Darcy, PhD, CEO and founder of Woebot Labs Inc. "Barriers, like cost of treatment and social stigmas, have prevented people from getting the help that they need," Darcy says. "Woebot represents a new era in digital health."
In a similar vein, psychologists are exploring the use of "Just-in-Time Adaptive Interventions," or JITAIs, delivered via smartphone. JITAIs seek to give people the support they need at the time they need it, such as smokers who are more likely to crave a cigarette when they are stressed or see someone else smoking.
"When it comes to unhealthy behaviors, you're more at risk of engaging in them at certain times," says psychologist Bonnie Spring, PhD, who directs the Center for Behavior and Health in the Institute for Public Health and Medicine at Northwestern University. "But in the classic model, where you see your therapist once a week, the therapist isn't there in the moment when you need help to overcome the temptation."
Spring and her team are equipping smokers with sensors that pick up users' heart rates and respiration patterns, and determine when they are stressed and when they are smoking. The team studies participants for several days while they are still smoking, then coaches them to quit by helping them cope with the stress of nicotine withdrawal. When a participant's sensor detects that they are stressed, for example, a relaxation app automatically opens on their smartphones. The idea is to prompt them to calm down by doing a relaxation exercise rather than reaching for a cigarette.
The goal of these technologies is to intervene in rapidly changing conditions that occur outside standard treatment settings while minimizing disruptions to a person's daily life and routines. "It's important to keep in mind that we can't just provide reminders every time a person experiences stress because people can get habituated to repeated reminders, or get irritated or feel overwhelmed if reminders are provided too frequently or at inconvenient times," says Inbal (Billie) Nahum-Shani, PhD, a University of Michigan behavioral sciences professor who is also studying JITAIs. That's why JITAIs are designed to offer an intervention only when the person is receptive. "To effectively provide just-in-time interventions, we need to be able to assess not only when the person requires support, but also when the person can actually benefit from it."
Meanwhile, research continues to document the promise of technology in psychology practice. A review of more than 100 controlled trials published last year concluded that therapist-guided internet treatments are effective for a wide range of psychological conditions (Annual Review of Clinical Psychology, Vol. 12, 2016). Evidence is particularly strong around the effectiveness of treating anxiety, stress and depression online (Journal of Technology in Human Services, Vol. 26, Issue 2–4, 2008). And new services such as BetterHelp, Therapy. Live, LARKR, 7 Cups and others tout on-demand talk, text or video therapy to provide consumers with greater flexibility (see "A Growing Wave of Online Therapy," February 2017 Monitor).
And in more good news for telepsychology practice, 31 states plus Washington, D.C., now have parity laws requiring insurers to cover telehealth services if they cover in-person care (although Medicare still reimburses for telehealth only outside metropolitan areas or in "health professional shortage areas").
Progress is also continuing on enacting the Psychology Interjurisdictional Compact (PSYPACT), which allows licensed psychologists to offer telepsychology services in participating states without having to get licensed in those additional states, says Alex Siegel, JD, PhD, director of professional affairs at the Association of State and Provincial Psychology Boards, the organization that developed PSYPACT.
Three states have enacted PSYPACT legislation and several more have introduced legislation to adopt it, but PSYPACT will only become operational once it is enacted in seven states.
Siegel says he expects that will happen in 2018. "It's no longer a question as to if PSYPACT will happen—just when."
● Psychologists who engage in telepsychology must consider legal requirements, ethical standards, telecommunication technologies, intra- and interagency policies, as well as several other external constraints. To help psychologists interested in this realm of practice, in 2016 APA released its Guidelines for the Practice of Telepsychology. Read them at www.apa.org/practice/guidelines/telepsychology.aspx.
By Amy Novotney
This article was originally published in the November 2017 Monitor on Psychology