Digital CBT – To be or not to be?
It’s official. Psychotherapy has gone all telemental.
Who would have thought it? Do you remember as Binik et al do when “ psychotherapy probably ranked high, just after motherhood and friendship on the list of domains least likely to be taken over by machines.” Well, scrap that. If, as the authors of ‘Culture of the Internet’ claim , ”Therapy is generally defined as a series of contacts between a professionally trained person and someone seeking help for problems that interfere with his or her emotional well-being, the question has to be asked, Is it really necessary for one to be in the presence of a therapist to improve?”.
The authors propose that , “if we generally conceptualise the therapeutic alliance as having three constituent parts, (a) an agreement between patient and therapist about therapeutic tasks or interventions, (b) an agreement about therapeutic goals (c) and an affective bond between therapist and patient based on trust, acceptance and confidence then such a conceptualisation potentially allows for easing the requirement that psychotherapy requires a human therapist”.
For those readers of a sensitive disposition I’ll just give you a second to process that but if you’ve been caught lagging you’ve only got yourself to blame. As Kathleen Smith says, “We no longer live in a world in which we can so clearly partition ourselves off from the electronic information grid. Many occupations no longer require a clearly defined workplace or a physical presence. Many employees never see their boss in person. Increasingly, surgeons are slicing patients open from hundreds or even thousands of miles away. Why should psychotherapy be any different?”.
‘BECAUSE IT IS! ’, would be my reflexive although admittedly childlike answer. I have and continue to dabble with skype and telephone counselling but I struggle to consistently achieve actual and technical connectivity . As I have said in a previous blog two warm bodies in the same room has always been my preference but I have to accept that some patients prefer service delivery choice and it would be churlish to deprive them of my big league therapeutic skills . Jokes.
Psychologist and author of ‘Dual Relationships and Psychotherapy’, Ofer Zur, dispenses a harsher judgement to those resisting the on-line therapy technological revolution. “Face-to-face is a self-serving mythology, therapists who hold onto the old images of the traditional way psychotherapy ‘should be’ are refusing to recognize the realities of the world in which they live.” Harsh.
However, like it or not, there’s no doubt that the evidence base for online therapy is growing. According to IESO Digital Health online psychological therapy is found to be more effective than other methods of therapy. Recent data published by the Health and Social Care Information Centre (HSCIC) has shown that IESO’s unique method of online CBT was more effective than other methods of psychological therapy delivered during the same period.
IESO claim that treatment delivered via live written conversation with an accredited therapist provided for patients suffering from anxiety and depression demonstrated a 49% recovery rate amongst its patients. This compares with the national average of 46%.
Furthermore, “The results also show that patients receiving therapist led online CBT are significantly more likely to complete therapy, with 57% of patients finishing treatment, in comparison with the 40% national average. These results come at a time when access to effective psychological therapies has been identified as a key area for improvement in the NHS. A new target has been set as part of the NHS Five Year Forward View for Mental Health to increase access to IAPT for people with anxiety and depression from 15% to 25% by 2020, equating to an additional 600,000 people accessing mental health treatment. With the limited financial resources available, healthcare commissioners and providers will have to think innovatively about ways of delivering treatment in order to meet this new target”.
Well, you didn’t think you’d be able to read a quote about innovations in mental health service delivery without the T word being mentioned did you? It’s not that I don’t appreciate the importance of objectives but the over- zealous implementation of targets as evidenced in IAPT services has unarguably been damaging to patients and clinicians. Priorities have become distorted and creativity stymied exposing CBT to the charge of being homogenised, soulless and protocol driven focusing solely on states of mind and excluding states of ‘being’.
The issue of being present with patients is deftly explored by psychotherapist Gillian Isaacs Russell who was moved to write Screen Relations: The Limits Of Computer-Mediated Psychoanalysis and Psychotherapy, following her experience of offering distant therapy to clients when she moved to a rural area of South Dakota.
While Russell is dubious of many aspects of online therapy, she believes it’s the perfect medium for cognitive behavioural therapy (CBT), positive psychology and self-help courses, which she describes as “dictatorial and not based on a relationship”.
This rather unflattering description of CBT is not one I recognise but I do find I spend quite a lot of time disabusing potential clients and colleagues of the idea that CBT is a prescriptive quick fix, more focused on ‘doing’ rather than ‘being’ and not remotely interested in an individual’s past experiences. Accurate or not these ideas have gained currency which is harmful for our organisation and deeply unfair to CBT therapists who rather than dictating therapy with their patients are more often than not the ones being dictated to by target obsessed managers.
That said, I can see why CBT and its fondness for structure, protocols and scheduling would translate well onto a screen and as the digital revolution is currently well underway we need to figure out how to make it both meaningful and effective .
Russell’s book goes a long way in helping us to do that by unpacking the challenges of telemental psychotherapy. It is an essential read for anyone wrestling with the impact of ever expanding technology on the talking professions. The author encourages critical evaluation of whether it is true, as some appear to believe , that screens and telephones can substitute for a physical presence and asks, “ Can it really be so that co-present bodies have become passe?”.
Russell invites us to develop a deeper understanding of what exactly happens during technologically mediated treatments and to guard against an over-focus on potential gains like low cost and accessibility whilst ignoring what might be lost in the process. After all, words are only one way of communicating and it is the silences in between that allow for emotions to surface and ‘a-ha ‘moments of insight to be discovered. What of the difficulty picking up non-verbal messages, the inability to be touchable, the loss of smell, the sound of a breath when the therapist and client are divided by a screen? Are there some therapeutic approaches that are better suited to the digital age and do we need to be more honest with our patients and ourselves about the differences? These timely enquiries are explored with eloquence and embedded in rich lived experience as a psychotherapist . The chapter focusing on direct experience of patients and clinicians using technology for treatment is particularly illuminating and helped make sense of the difficulties I have experienced when providing therapy in this way.
It is important to acknowledge the circumstances when digital therapy is not only useful but may be the only viable option for some, e.g. patients on limited incomes, those living in remote areas, time poor, those already engaged in a therapeutic alliance but who move out of area and want continuity. However, as valuable as these advantages are we all need to be concerned about government plans to create a fundamental shift in the relationship between citizens, the internet and the state with the introduction of the Investigatory Powers Bill. Under this law almost every digital communication and movement would be logged by telecommunications companies, intercepted by intelligence agencies and subject to scrutiny and compromises the therapists professional responsibility to provide a therapeutic ‘safe space’.
For the independent practitioner the advancement of technological therapies reminds us that in a flooded market place with the spectre of job insecurity hanging over many it’s likely that more practitioners will be focusing on clinical survival and are likely to be attracted to providing digital therapy. Indeed many of the major Health Insurance providers encourage their registered therapists to provide this service not least because the fee’s chargeable are less than face to face. My sense is that IP’s are naturally innovative , are accustomed to using technology to support their business aims and may already have developed the skills sets necessary to provide a high quality digital therapy service. However, as the role of technology in the provision of psychological services expands, those like me, who have been a little slow off the mark may find there is a risk of someone else eating your lunch.
So, to be or not to be? That is my question. I’m still trying to figure out what impact digital therapy might have on the way I practice What I do know though , is that my son is leaving for Australia in September and no amount of face- time, facebook, skype, whatsapp , snapchat, vine or periscope will ever replace ‘be’ ing with him , in all his dimensions.