Anxiety disorders are the most common mental disorders and they account for approximately one-third of all mental health care costs (for references see the full paper linked below). Fortunately, meta-analyses show exposure-based therapy is effective for most patients with anxiety disorders. Based on such findings, international treatment guidelines recommend exposure therapy for anxiety disorders as the gold standard (e.g. National Institute for Health and Care Excellence [NICE]). For example, the Institute of Medicine stated “the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD” (p. 97) but they did not find sufficient evidence for any other psychotherapy or pharmacotherapy. Following these guidelines should be uncomplicated, but in general therapists seem to prefer to use their clinical experience rather than research findings to improve their practice.
Although well supported for over 50 years, most people with anxiety disorders still do not receive exposure therapy. In fact, most people with emotional disorders do not receive any treatment. This gap in what is known and what is available to patients is frustrating. Examination of obstacles to dissemination reveals how recent advances in technology may help bridge the gap. Below we briefly review some of the proposed obstacles to successful dissemination and potential technological solutions for each.
Obstacle: Difficulty Creating Exposure Scenarios
Solution: Virtual Reality Exposure Therapy (VRET)
Many exposures can be difficult to create in the office. Certain fears (i.e. flying, heights, public speaking and other realistic social scenarios) are largely dependent on an external environment that would not be feasible to generate in an office setting. Virtual reality exposure therapy (VRET) has been a helpful and effective way to expose patients to these stimuli. However, there has been relatively little advancement in realism (presence) until recently. Several emerging technologies will likely make VRET a central mechanism of exposure therapy in the near future. First, the lower cost and higher quality of video capture has suddenly surged forward. GoPro cameras and rigs now make 360 degree 3D HD film a possible mechanism of realistically experiencing most any scenario. Second, the lower cost and higher quality of head-mounted displays make delivery of these interactive 3D (side-by-side) HD film scenes accessible to anyone. This movement began with the Oculus Rift but now extends to any smart phone coupled with an inexpensive head-mounted rig (e.g. Google Cardboard). Once enough content is created, therapists can simply mail a rig and conduct exposure remotely. A first step in that direction is the ongoing randomized controlled non-inferiority trial where a single-session gamified virtual reality exposure therapy for spider phobia is compared to traditional exposure therapy.
Obstacle: Low Consumer Awareness
Solution: Symptom Feedback and Gamification
Web-based psychological treatment programs and applications now track and provide instant graphs of symptom progression. These internet interventions have shown promise in treating psychiatric problems. Even psychophysiology can be relatively easily tracked with products such as eSense (skin conductance), Emotiv (EEG), and the Withings Pulse O2 (pulse oximetry). These can all provide significant positive reinforcement and increase motivation to complete exposures and homework. In addition, by adding smartphone applications with game playing elements, such as points or badges, to a face-to-face therapy could increase the likelihood of homework being completed. One such example is the Challenger smartphone app for social anxiety that provides personalized behavioral experiments based on the user’s current location.
Obstacle: Low Consumer Awareness
Solution: Direct to Consumer Marketing
A large proportion of people meeting DSM-criteria are unaware that they even have an “anxiety disorder” and do not know that it is treatable. This makes searching for the right provider nearly impossible. Also, most efforts to disseminate therapy follow a top-down approach (focused only on providers). A lesson learned from the pharmaceutical industry is the success of direct to consumer marketing. In this model, treatment is directly marketed to the consumers using strategies such as focusing on the potential positive impact of the treatment in recognizable terms rather than the pain of the symptoms (e.g. “would you like to be more comfortable flying?” rather than “do you have a specific phobia of flying?”). However, this needs to done in a balanced manner to prevent possible overselling.
Obstacle: Limited Access to Experts
Solution: Expert Systems
Acquiring a high level of clinical expertise may be important in order to reach the efficacy rates observed in randomized trials. However, it has been estimated that it would take 10 years to reach an expert skill level at 20 therapy hours per week—assuming someone is practicing “correctly”. Few practitioners have the time to devote to learning each evidence-based treatment to an expert level. However, online training can accelerate this process and new computer programs designed with expert input can provide decision trees and assistance in expert delivery of treatment packages. Computer delivery of CBT will also make it more efficient to conduct well-powered and generalizable studies.
Obviously this is a truncated list of the myriad ways technology will likely contribute to the ongoing growth in the field of CBT. This brings us back to our journal Cognitive Behaviour Therapy and our continued mission to be the home of state-of-the-art research on the nature, causes and treatment of mental disorders from the cognitive behavioral perspective. The coming year is sure to show more applications for technology in the advancement of CBT for mental health.
Read the full text with references:
Powers, M. B., & Carlbring, P. (2016). Technology: Bridging the Gap from Research to Practice. Cognitive Behaviour Therapy, 45(1), 1-4. doi:10.1080/16506073.2016.1143201 [50 FREE COPIES HERE!]