12 Jan 2018

Technology is Revolutionizing Practice

Technology is Revolutionizing Practice

Apps and virtual help agents are forever changing the way psychological services are delivered

Once mainly the domain of rural practitioners, telepsychology is expanding significantly, thanks to technological innovations, research that shows its effectiveness and policy changes that are enabling psychologists to practice across state lines.

"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

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11 May 2017

Should you use an app to help that client?

Should you use an app to help that client?

As the use of mental health and behavioral apps grows, psychologists must weigh their benefits and limitations

Today there are more than 165,000 health-related apps worldwide, helping users track their diet and exercise, monitor their moods and even manage chronic diseases, according to a 2015 report by the IMS Institute for Healthcare Informatics. Nearly 30 percent of these apps are dedicated to mental health. While the apps present new opportunities for psychologists to boost patient support and supplement the therapeutic relationship, their sheer number and variety can make it difficult for psychologists to determine which are the most effective, safest and most useful.

"There's been an explosion of apps, and clinicians don't have time to keep up with all of them," says Stephen Schueller, PhD, a clinical psychologist at Northwestern University's Center for Behavioral Intervention Technologies. "It's not their job and it's impossible for them to do it."

But since one in five Americans uses these apps, staying informed about broad trends in app use is important for psychologists, says David Luxton, PhD, co-author of "A Practitioner's Guide to Telemental Health" (APA, 2016).

"If you're not familiar with these technologies today as a clinician, it's time to start paying attention because our patients are demanding them," he says.

Why use apps?

Many practitioners find that mental health apps are a valuable adjunct to psychotherapy because they allow therapists to maintain a better connection with their patients and improve their ability to track clients' symptoms and moods. Some of the most widely used of these apps include T2 Mood Tracker, developed by the National Center for Telehealth and Technology (T2), and Optimism Online, a mood charting app that allows clinicians to monitor client entries and receive alerts to help catch problems as they arise.

San Francisco-based clinical psychologist Keely Kolmes, PsyD, says that many of her clients prefer apps to the paper-based tools that she's used in her practice for years, for recording thoughts and tracking moods.

"Apps help prompt my clients to log things like their mood or whether they exercised or drank alcohol or slept well, so that I can have an accurate picture of their week, as opposed to them trying to reconstruct things on paper the day before therapy or during therapy, which is much less reliable," she says.

Apps are also available to patients 24 hours a day, seven days a week, and can be a great source of educational information, particularly at times when a client's clinician is unavailable. These include several apps by T2, such as PTSD Coach and CPT Coach, as well as Day to Day, which delivers a daily stream of advice, support and other information throughout the day to boost a user's mood. Day to Day is one of 14 apps included in IntelliCare, a suite of apps developed by Northwestern University's Center for Behavioral Intervention Technologies that target depression and anxiety arising from various causes.

While more research is needed, several studies indicate that the use of health apps can also improve patient outcomes and satisfaction. A 2015 meta-analysis led by Harvard Medical School psychiatrist John Torous, MD, for example, looked at 10 studies examining the use of apps in the treatment of mood disorders. The analysis found that patients who used these apps reported improved depressive symptoms (Internet Interventions, 2015). And a 2013 study led by University of New South Wales psychologist Tara Donker, PhD, found that participants who used apps reported the apps were a useful way to get self-help for mental health concerns and disorders (Journal of Medical Internet Research, 2013).

Apps can also help clinicians gather data about their practice, says APA's director of legal and regulatory affairs, Stacey Larson, PsyD, JD. For example, several apps provide HIPAA-compliant note-taking (such as Insight Notes and Mobile Therapy) and can generate graphs or tables showing client improvement as well as areas that still needed to be worked on. "A provider can use them to help determine which interventions are working best and which should be changed, and this information can be shown individually or charted for a practitioner's whole practice, to determine how interventions are working more broadly across their patient population," Larson says.

Potential limitations

Despite their popularity, behavioral health apps are not regulated and many are not research-based, says Marlene Maheu, PhD, executive director of the Telemental Health Institute in San Diego.

"We're scientists—we need to have evidence that something works before we use it with our clients," she says.

Schueller agrees, and encourages clinicians to look for apps that come with documentation of the evidence on which they are based, including research on the intervention underlying the app, such as cognitive-behavioral therapy, as well as research specifically associated with the app itself.

"The most reputable apps are generally those affiliated with academic research institutions or government funding agencies, as they are the most likely to detail the app development and validation process," he says. (See list below.)

Patient privacy and security concerns also need to be addressed any time technology is used in clinical practice. Some apps, for example, allow communication between therapists and patients between sessions—a feature some therapists might want and others might not—and it's crucial that this communication be HIPAA compliant, Maheu says. It's also important for providers to understand what, if any, data are being collected when a patient uses an app, and to make sure patients are informed about this, Larson says.

"Mobile mental health apps can be either passive or active," she explains. "Active apps require direct participation from the patient—such as completing mood logs, self-symptom ratings or recording personal experiences, but passive apps are able to access information independently and gather data through smartphone functions such as GPS without the patient or provider even noticing. Though it may be beneficial, some people may not like the potential invasion of privacy associated with this type of data gathering." And Schueller advises clinicians to show patients how to put a screen lock or password on their phones for additional security.

Integrating apps into your practice

With all of these limitations in mind, how can practitioners ensure the best use of apps in practice? Schueller recommends asking colleagues how they may use apps in therapy, and posting questions on listservs to find out what others have found works best. Several organizations provide resources and reviews of mobile health apps, to help clinicians stay abreast of the most effective and safest technologies. (See list below.) APA and the Center for Technology in Behavioral Science also hosted a webinar in May exploring the role of apps in clinical practice. The organizations received an overwhelming response to the one-hour event, with more than 1,700 clinicians registering for the event, says Maheu, CTiBS president and CEO. Two more webinars are being scheduled for the fall. It's also imperative that psychologists take time to test an app themselves before endorsing it with their clients, Luxton says.

"Install it and try out every single possible scenario inside that app so that you know it very well," he says. And always get feedback from patients on how an app is working for them, Schueller says. "As you start to learn more about which apps are really resonating with the population of clients you're working with, it will help get your practice more in line with what your clients want."

And most important, he adds, clinicians must be mindful of how apps fit into the goals of therapy. "Apps are not a panacea," Schueller says. "There's a lot of enthusiasm here and some of it is warranted. But be cautious; they will not completely fix everything."

APA does not endorse any of the apps mentioned in this article.

Mobile health app resources

By Amy Novotney


This article was originally published in the November 2016 Monitor on Psychology

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21 Apr 2017

A Growing Wave of Online Therapy

A Growing Wave of Online Therapy

The flexible nature of these services benefit clients and providers, but the onus is on psychologists to make sure they comply with federal and state laws

It was an ad on Facebook that first prompted Los Alamitos, California, clinical psychologist Nina Barlevy, PsyD, to visit the online therapy website BetterHelp.com. The company promoted affordable online counseling, available anytime and anywhere, and Barlevy thought joining their panel of therapists might be a great way to supplement her income during slow times in her private practice.

"It looked like a good way to expand my practice here and there in my free time, if I was already going to be on my computer in the evenings or on my days off anyway," Barlevy says.

She went through Better Help's rigorous application process, which included verifying that she was licensed, and began communicating with users in her state via the site's secure messaging platform. The site also offers members the option to schedule live video and phone sessions with their therapists, though Barlevy worked mainly with clients via the site's unlimited asynchronous messaging service. They messaged her about many of the same issues her face-to-face therapy clients were dealing with, including stress, anxiety and relationship issues, among other concerns, and she messaged them back with questions, feedback, insights and guidance. They benefited from easier access to therapy, which particularly helps people in rural areas who may not be able to drive an hour each way to see a therapist face-to-face.

"[It is] a whole lot more appealing to be able to sit at your computer and type back and forth with someone," Barlevy says.

Telepsychology, be it by phone, webcam, email or text message, has been around in one form or another for more than 20 years, used most often by members of the military. But the explosion of smartphone users has created new opportunities for app-based companies to offer more accessible and affordable therapy.

Still, such online therapy creates concerns over patient privacy, as well as legal and ethical issues, including interjurisdictional practice issues, for providers who contract to work for these companies, which may not share the same code of conduct and commitment to do no harm, says Deborah Baker, JD, director of legal and regulatory policy in APA's Practice Directorate. Many of these online therapy companies also are not run by psychologists.

"When you're an individual provider, you can't assume that a business is going to be looking out for your best interest, so you really have to dig a little deeper and check in with your professional association and malpractice carrier to make sure you're complying with the law and with the APA Ethics Code."

Benefits for patients and therapists

The growth in online therapy companies—nearly a dozen have launched in the last several years—doesn't surprise Lindsay Henderson, PsyD, assistant director of psychological services at Boston-based telehealth company American Well, which offers therapy through video conferencing. The ease and convenience of scheduling a therapy appointment online and talking with a therapist from the privacy of one's own home—or wherever one may be—is a huge draw for consumers, many of whom are seeking therapy for the first time in their lives, she says.

American Well's online platform helps "normalize mental health care, especially among generations now who are so accustomed to interacting with people using technology," Henderson adds. "It just eliminates so many barriers."

Research studies, many of which are listed in bibliography format by the Telemental Health Institute, also indicate that telemental health is equivalent to face-to-face care in various settings and an acceptable alternative. While much of the research tests only the use of videoconferencing as the telehealth modality, a few studies, including two published in 2013, have also shown that asynchronous messaging therapy can be as effective as in-person therapy (Journal of Affective Disorders and Cyberpsychology, Behavior and Networking).

Even more encouraging is that when digital interventions are positive, effective experiences for patients, they may go on to seek face-to-face therapy, says Megan Jones, PsyD, adjunct clinical assistant professor of psychiatry and behavioral sciences at Stanford University School of Medicine. A study she led found that college students who needed a higher level of care for eating disorders were more likely to seek it out after participating in a digital body-image program and working with a coach online via asynchronous messaging through the online therapy company Lantern (Journal of American College Health, 2014).

"It can really be a nice first step in treatment for someone who needs more intensive therapy," says Jones, who also serves as chief science officer at Lantern.

Mental health professionals can also reap benefits from joining online care teams. In addition to supplementing practitioners' incomes with new patients, providing online therapy can help them maintain a better work-life balance, Henderson says.

"From the provider perspective, the flexibility of practicing telemental health fits so well into my life and allows me to better meet my patients' needs," she says. "I'm not at a point in my life where I want to be going to an office at 8:30 in the evening, but I will happily go to my home office, lock the door and see a patient at that time."

Employment at online therapy companies isn't limited to providing therapy to clients, either. Opportunities abound and will continue to grow in supervisory and training roles as well as full-time research positions at these mental health technology companies, Jones says.

But tread carefully

Of course, online care is not for every patient or practitioner. Clients with more serious mental illnesses or addictions likely need more treatment than digital therapy can provide. And some clinicians may find certain telehealth modalities difficult, says Barlevy.

"I'm such a people person, so it was tough for me to feel a real connection when I was just messaging with people," she says. "Plus a lot of people just stopped responding, and I felt like there wasn't enough time to really build a relationship. It actually turned out to be more difficult than I imagined."

In addition, some online therapy companies don't have clear guidelines for handling risky situations, such as a patient who may seem suicidal in his or her messaging responses, says Lynn Bufka, PhD, associate executive director for practice research and policy at APA.

While some apps do report that they use a member's IP address to determine their exact location and send police if a therapist is concerned about a member's safety, it's often more difficult to determine a patient's level of risk via a messaging app than face-to-face with them in a therapy room.

"If you're using an online therapy platform and you ask someone if they're suicidal and they say no, is that it?" Bufka says. "Those kinds of clinical issues come up, which is why I think most psychologists seem to feel much more comfortable integrating technology into an ongoing face-to-face or video/teleconferencing relationship versus using only messaging."

Practitioners also need to do their due diligence when it comes to making sure their decision to contract with an online therapy company doesn't run afoul of complying with the Health Insurance Portability and Accountibility Act (HIPAA), state licensing laws and other legal and ethical practices, Baker says. In addition, platforms that allow patients to connect anonymously with therapists may create legal and ethical issues for psychologists.

"My concern is that some of these models are probably start-ups that are launched by people in technology, who have good intentions but haven't fully investigated all the nuances in what's involved in providing health services," she says. "Do they fully understand HIPAA/HITECH, any related state laws and patient confidentiality policies? Do they fully understand that psychologists cannot simply provide services to patients anywhere in the United States?"

Psychologists interested in joining these companies should investigate those issues, and also find out exactly where patients are located if they are providing them therapy services to ensure that they are authorized to do so. Such issues were part of the reason Columbia, South Carolina, clinical psychologist Shawna Kirby, PhD, decided to part ways with an online therapy company she worked for in 2015. After several months as a contracted therapist, she terminated the agreement, due to a series of ethical concerns she had over how the company dealt with interjurisdictional practice issues, consumer privacy, informed consent and therapy termination. When she brought her concerns to the company's clinical director and owners, none of whom are psychologists, she says they brushed off her concerns, and then eventually blocked her from messaging with her clients. "It all seemed more financially driven, rather than care driven," she says.

That's why it's so important that psychologists play a leadership role at mental health technology companies, Jones says.

"These companies need our knowledge and competency at the heart of their decision-making process because we have a very different framework and we understand the responsibilities that we have to users in a very different way than you do if you come from a technology background," she says. "I want to have a peer at any company like ours."

By Amy Novotney


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