Computerized Behavioral Therapy Could Boost Access to Care, but Barriers Remain

Facing a shortage of behavioral health providers, California has been forced to explore innovative, cost-effective ways of delivering care. One such option is computerized cognitive behavioral therapy, or cCBT.

Cognitive behavioral therapy is an evidence-based form of treatment that teaches patients to re-evaluate the way they think, and in effect make positive changes to their behavior. Such programs are available for treatment of depression, anxiety disorders and other psychiatric conditions. cCBT leverages technology — such as computers, multimedia programs, virtual reality and handheld devices — to deliver such treatment virtually.

cCBT holds promise for Californians suffering from mental health issues, but recent pilot studies conducted at safety-net clinics in the state suggest that multiple obstacles must be addressed before the therapy can be more widely implemented.

Studying Use of cCBT at Safety-Net Clinics

Safety-net clinics frequently see patients with chronic pain or depression. Cognitive behavioral therapy has been found to be effective for both conditions, but a shortage of behavioral health providers in the state makes timely treatment in the safety-net setting challenging.

The California Healthcare Foundation funded two pilot studies — one focused on depression and one focused on chronic pain — to determine how digital programs could boost access to such care. CHCF publishes California Healthline.

The first pilot was administered by the California Institute for Behavioral Health Solutions and geared toward adults with mild-to-moderate depression at community clinics in San Joaquin and Modoc Counties. Patients were offered the Beating the Blues program, a series of eight 50-minute video cCBT sessions.

Out of the 100 targeted referrals, only 19 individuals participated in the program, with just 5 of those referrals moving on to the second of eight sessions. No participants made it far enough in the program to complete the consumer satisfaction survey and receive the incentive.

The second pilot was conducted by the San Francisco Health Plan administered and geared toward adults seeking non-medication alternatives to chronic pain treatment at five city clinics. ReThink Pain is a 12-lesson e-learning program involving educational information and interactive exercises.

Online behavioral health services provider Empower Interactive led training sessions on its ReThink Pain program at each of the participating clinics. However, only 21 patients had signed up to participate within the first three months.

Barriers to Leveraging cCBT

Despite the promise of cCBT in bolstering access to behavioral health care, both pilot programs faced multiple setbacks to full implementation.

Erika Van Burren, who evaluated the Beating the Blues pilot, said the main barriers included “the technological infrastructure,” as well as “lack of resources and staff available to devote to learning the technology.”

Implementation barriers in the Beating the Blues pilot included:

  • Lack of adequate staff guidance;
  • Lack of reliable Internet access;
  • Challenges targeting appropriate patients;
  • Technical challenges;
  • Technology incompatibility with patient needs; and
  • Time securing contracts and information security processes.

Meanwhile, barriers to implementation in the ReThink Pain pilot included:

  • Failure to secure a marketing partnership with the San Francisco Health Plan;
  • Lack of computer access among patients;
  • Limited patient computer literacy; and
  • Issues with patient and staff motivation.

Benefits of cCBT Pilots

Despite the barriers uncovered during the pilots and the fact that both programs failed to reach full implementation, staff members identified several areas in which Beating the Blues and ReThink Pain showed promise for both patients and providers.

Both sites participating in the Beating the Blues pilot reported that patients expressed real interest in the program and enjoyed its self-paced format. At the end of the pilot, participating staff at the Modoc and San Joaquin clinics continued to endorse the program as a low-cost alternative to traditional therapy.

Meanwhile, ReThink Pain staff touted the program for the independence it offered patients as “a new tool for how to think about their pain.” Providers enjoyed ReThink Pain’s content and curriculum and recommended the program as a tool for patients who were already involved or interested in non-medication alternatives to chronic pain treatment.

Brenda Major — a professor in the department of psychological and brain sciences at UC-Santa Barbara — told HealthDay/U.S. News & World Report that computer-based cognitive behavioral therapy “makes a lot of sense,” adding, “I think that in theory a Skype therapy session, or even an immersive virtual reality type session, could be very effective.”

“But the real question,” she said, “is how good is the therapist? Because whether they’re sitting on the couch opposite you or on the other end of the computer, you want a therapist who is well trained and highly rated. Therapy provided face to face can be very ineffective with a bad provider. The same would be true online.”

Recommendations for Future cCBT Programs

Through discussions with the pilot participants, evaluators made several recommendations to improve cCBT programs in safety-net clinic settings:

  • Adequately prepare staff through consistent formal training;
  • Adopt a system to monitor patient performance;
  • Implement programs in clinics that are already well-staffed and well-resourced;
  • Integrate compliance processes;
  • Use assessment and data analytics tools to identify patients who would most benefit from cCBT;
  • Use motivational interviewing techniques to bolster patient outreach;
  • Offer patients and staff incentives to complete programs;
  • Provide patients with tools to best utilize cCBT technology; and
  • Provide program instruction in languages other than English.

Jennifer Covich Bordenick, CEO of the eHealth Initiative, said, “These studies demonstrate why the patient needs to be the focus, not the technology. Patient motivation, engagement, usability were all key factors here.” She added, “More importantly, you can’t replace human touch with a video. Clinicians and innovators should use the learnings garnered from this work to improve future treatments that might utilize these types of technology.”

In a Harvard Health blog post on a separate cCBT study last week, James Cartreine — a licensed clinical psychologist and a researcher in the Brigham and Women’s Hospital’s Program on Behavioral Informatics and eHealth — wrote, “The biggest challenge isn’t building a cCBT program that works; it’s building one that people will use. Just as you need to entertain before you can educate, any cCBT program needs to be extremely engaging to users — and to provide immediate value from the first session.”

He added that “although the treatment-anywhere-anytime concept is alluring, relying on people to schedule cCBT themselves on their own time, in their own homes, may lead to high levels of drop-off; after all, you can always get around to it later.”

Additional research is necessary to assess the effectiveness of cCBT in safety-net facilities, but continuing to adjust the current model can lead to improved outcomes.

“I actually think [cCBT] can work anywhere if the right resources are in place,” Van Burren said. “I’m hoping that we won’t give up on this. I’m hoping we continue to explore for whom in what settings with what support and resources this can possibly be used.”

Covich Bordenick said, “Pilots like this are critical. Much of this technology is untested, and it will take significant experimentation to determine where and how it should be used. “

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