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The Future of Computer-assisted Cognitive Behavioral Therapy

The Wall Street Journal had a very interesting article yesterday, titled To Be Young and Anxiety-Free, focused on the value of cognitive behavioral therapy to help children with high levels of anxiety learn how too cope better and prevent the snowball scenario, when that anxiety grows and spirals out of control resulting in depression and similar

– “…new research showing that treating kids for anxiety when they are young may help prevent the development of more serious mental illnesses, including depression and more debilitating anxiety disorders.”

– “Of course, most kids have fears without having a full-blown anxiety disorder. And some anxiety is healthy: It makes sense, for example, to be a little nervous before a big test. Doctors and psychologists do caution that the increased focus on childhood anxiety could lead to an overdiagnosis of the problem. What makes anxiety a true illness is when it interferes with normal functioning or causes serious emotional and physical distress.”

– “But the use of antidepressants in children has come under fire because of recent evidence showing an increase in suicidal thoughts in kids taking the drugs. Partly as a result, many doctors and psychologists employ as a first line of treatment cognitive behavioral therapy, or CBT, which is often just as effective as medication.”

Full article: To Be Young and Anxiety-Free.

What is Cognitive Therapy (the most common  type of cognitive behavioral therapy) and what are its cognitive and structural brain benefits? Judith Beck guides us here:

– “Cognitive therapy, as developed by my father Aaron Beck, is a comprehensive system of psychotherapy, based on the idea that the way people perceive their experience influences their emotional, behavioral, and physiological responses. Part of what we do is to help people solve the problems they are facing today. We also teach them cognitive and behavioral skills to modify their dysfunctional thinking and actions.”

– “For years, we could only measure the impact of cognitive therapy based on psychological assessments. Today, thanks to fMRI and other neuroimaging techniques, we are starting to understand the impact our actions can have on specific parts of the brain.”

– “For example, take spider phobia. In a 2003 paper scientists observed how, prior to the therapy, the fear induced by viewing film clips depicting spiders was correlated with significant activation of specific brain areas, like the amygdala. After the intervention was complete (one three-hour group session per week, for four weeks), viewing the same spider films did not provoke activation of those areas. Those individuals were able to “train their brains” and managed to reduce the brain response that typically triggers automatic stress responses. And we are talking about adults.”

Full interview with Judith Beck: Here

Cerebrum, a publication by the Dana Foundation, just released an excellent article with background on cognitive therapy: how the technique was developed and refined, its short and long-term benefits, and future trends. See A Road Paved by Reason

– “Cognitive therapy is one of the few forms of psychotherapy that has been rigorously tested in clinical trials. It was first developed to treat depression, but its benefits extend to obsessive-compulsive disorder, post-traumatic stress disorder and perhaps even such “physical ailments as hypertension, chronic fatigue syndrome and chronic back pain.”

– “Psychological problems result from the erroneous meanings that people attach to events, not from the events themselves.”

– “In cognitive therapy, patients learn through a variety of strategies to test their faulty beliefs. They then learn to appraise themselves and their futures in a way that is realistic, unbiased and constructive.”

– “He (founder Aaron Beck) found that people who are depressed systematically block out the positive aspects of their life, seeing only the negative. They interpret ambiguous events in a negative way, which he describes as cognitive distortion. If something genuinely negative does occur, they tend to exaggerate its magnitude, significance and consequences. A minor error becomes a major catastrophe.”

– “Although cognitive therapy usually focuses on problem solving in the present, by doing that task the patients also develop lifelong skills…The authors speculated that the lasting effects of cognitive therapy reflect the patients new-found ability to “do the therapy for themselves. They remarked that the strategies learned “eventually become second nature, coinciding with a parallel change from problematic underlying beliefs to more adaptive ones.

– “Various managed-care companies and mental health centers now expect their therapists to be trained in cognitive therapy. The British government has recently set up a large program for training over 6,000 mental health workers to do cognitive therapy. There are now dozens, if not hundreds, of researchers focusing on the theoretical underpinnings of cognitive therapy, or on its applications.

Full article: A Road Paved by Reason

In short, here we have a number of major societal problems (anxiety, depression…) that affect people of all ages, and an intervention that teaches people cognitive skills to be able to manage those related challenges better.  Talk about “teaching how to fish” vs. simply handing out fish (which we could argue is what antidepressant medications do).

Why don’t more people benefit today from that approach? A major problem, in my view, is the lack of a scalable distribution model. Meaning, using the traditional face-to-face approach, one needs to create, train, certify, ensure quality of, a very large  network of practitioners. Which is what, as  mentioned above, the British government is doing: training 6,000 mental health workers.

This is certainly a worthy initiative. Now, is it the most scalable one to deliver results while being cost and resource efficient? Perhaps not.

We can view cognitive therapy as a method for well-structured cognitive exercise, where a key factor of success is practice. Same as training your abdominal muscles: if you just join the local club, which has a set of superb machines for abdominal training, but don’t use abdominal trainingthose machines in a disciplined manner, your abdominal muscles are unlikely to become very impressive.

We can then view the therapist as the personal trainer who motivates you to stay on track, to propose the right exercise routine based on your personal goals. If the trainer is with you the whole time, encouraging you to do and monitoring your abdominal exercises, you are most likely to complete them. But it is a very expensive approach.

Perhaps a hybrid approach makes more sense: the personal trainer helps you define goals, supervise progress and make modifications to the training regime, AND you do your own abdominal exercises with the machine that has been designed precisely with that goal in mind. There were no such mainstream machines only 50 years ago, before physical fitness became a popular concept and practice. Now there is one in every health club and TV infomercial.

Let’s go back to cognitive therapy. Of course there is a need for more and better trainer professionals who can help patients. But of course technology will help complement existing approaches, reaching corners we can not even predict now, and helping more people of all ages better cope with change, life, anxiety, a range of cognitive and emotional challenges. Without any stigma. Just as naturally as one trains abdominal muscles.

There is already research showing the value of computerised cognitive therapy. A recent systematic review published in the British Journal of Psychiatry concluded that

“There is some evidence to support the effectiveness of CCBT for the treatment of depression. However, all studies were associated with considerable drop-out rates and little evidence was presented regarding participants preferences and the acceptability of the therapy. More research is needed to determine the place of CCBT in the potential range of treatment options offered to individuals with depression.”

Yes, more research is always needed. However, we also need to refine the questions. Not so much “Will computerized cognitive therapy leave thousands of therapists out of work?” but “How can computerized cognitive therapy be used to increase the reach and effectiveness of therapists” and “Can computerized cognitive therapy help reach populations that receive no intervention whatsoever today?”

Think about that next time you see this:

abdominal training

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6 Responses

  1. cinderkeys says:

    but its benefits extend to … perhaps even such “physical” ailments as hypertension, chronic fatigue syndrome and chronic back pain.

    Myalgic encephalomyelitis (also known by the unfortunate name “chronic fatigue syndrome”) is a real physical illness. Research done on the effects of cognitive behavioral therapy on ME included subjects who don’t actually have it — that is, they experienced garden-variety fatigue due to depression, but not the crushing post-exertional malaise characteristic of true ME. CBT (along with graded exercise therapy) made some of the subjects worse (most likely the ones with true ME), and those subjects dropped out of the study. CBT had mild beneficial effects for the subjects who stayed.

    Researchers came to the conclusion that CBT helped people with “chronic fatigue syndrome” after excluding the subjects who dropped out from the results

    CBT is perfectly appropriate for people with physical illnesses as long as it’s understood that the goal of therapy is to help them cope with the reality of living with said illnesses. Using CBT and graded exercise therapy to help “cure” people with ME, however, will do far more harm than good.

  2. Good comment. I agree with part of it, disagree with another.

    Yes, it can not be said that CBT can “cure” ME or a number of other clinical conditions, simply because, to start with, many conditions are not objectively diagnosed. CBT can not be said to cure ADD, for example, it the same way that Ritalin or other drugs don’t cure ADD, either. And it is also true that, for CBT to work, people need to stick to the practice so compliance is an issue-which is why I used the physical fitness analogy.

    Now, CBT does more than just “help them cope with the reality of living with said illnesses”. Cognitive therapy can help reduce the symptoms of said illnesses in a variety of scenarios, from depression to phobias to obsessive- compulsive behavior, and in more sustainable ways (lower reincidence rates) than medication. The brain is as physical as any other organ and scientists are starting to discover the relationship between brain functions and brain structure, opening the way for research-based non-invasive interventions.

    In summary, I’d say that healthcare professionals would do well in adding a cognitive frame to many of their practices to enhance the lives of their patients. It is not one or the other, but how they can complement each other.

  3. cinderkeys says:

    If CBT (minus GET) can reduce stress for ME patients, that has value. I’d like to see studies with much better methodology being done, though. I’d also like to know if the benefits of therapy outweigh the physical toll it takes on some ME patients just to make it to the session. Therapists, alas, generally don’t make house calls.

  4. Mike Logan says:

    Hello All,

    Would love to see the programs being used in the computerized Tx. of depression. Thanks.

  5. Nerissa Belcher says:

    From the post: “Psychological problems result from the erroneous meanings that people attach to events.” This is not literally true. Research shows depressed people are more accurate than optimistic ones. Cognitive therapy attempts to convince people the value of being less accurate by fooling them into thinking they are more accurate. A more direct approach to mental health is to not worry about accuracy and just enjoy life.

  6. Hello Nerissa, I think you are mixing things. First, research doesn’t show that depressed people are more accurate than non-depressed people (the relevant comparison here). Second, cognitive therapy doesn’t try to fool anyone. Third, and most important, there are dozens of published studies showing the value of cognitive therapy. Can you please share the list of references behind your suggested “more direct approach”? (to just enjoy life is a great goal…but pretty useless as the process to get there for people who need a bit more help)

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