5 ways technology can specifically enhance technological treatments for mental disorders
By Javier Fernández-Álvarez
Although it may sound a truism, suffering is constitutive of humanity. Human suffering is, in this sense, as old as humanity itself. Worldwide, millions of people severely suffer from their psychological difficulties to cope with reality. Sometimes, when an individual’s behaviors are presented in an organized dysfunctional form, the suffering experience may be subject of classification and thus labeled as a mental disorder.
But… What has been done throughout history to alleviate human suffering? Numerous coping strategies have been developed, both in spontaneous and systematized forms. From remote times, religions, philosophers and lay people have analyzed and proposed possible paths to deal with those problems derived from the inner and collective struggle to coherently organize reality and enhance the experience of control. Nevertheless, it has been the scientific approach the one that achieves to systematically examine the causes, forms and manifestations of mental dysfunctions (psychopathology), to generate instruments to objectively (as much as possible) gauge mental states (assessment) and to produce a vast array of tools to intervene and improve people’s quality of life (e.g. psychotherapy). In particular, in the last century we experienced the sprout out of hundreds of models that showed to a certain extent to have evidence supporting their efficacy for the treatment of mental disorders. Thousands of articles, books and handbooks compile this evidence; the whole scientific community is working strenuously on expanding this body of knowledge. More importantly, there is a shared belief that certain sorts of mental dysfunctions are treatable in an efficacious way.
However, not everything that shines is gold. Despite indisputable advancements, psychological treatments are far from being at an ideal state. Several problems are pending to be resolved. In a nutshell, the prevalence of mental disorders is dramatically increasing, with some conditions, such as depression, leading the rankings of causes of disability. Although treatments are showing to be efficacious, very little is known about how these treatments work, which in many cases this means that it is not possible to know exactly what therapists should do to help their clients. In other cases, research is more conclusive and thus it is clearer how to proceed. Nevertheless, there are also dissemination problems for which the available knowledge cannot be properly translated into hospitals, primary care settings, private practices, etc. The fact that there is a gap between research and practice is not new, but not therefore less pervasive.
In this sense, how would be the image that would come up to your mind when you think in words like “psychotherapy”, “psychological treatment” or “clinical psychology”? Most probably, something like this… A therapist and a client, in front of each other in a dialogical disposition.
In 2011 two well-known American researchers (Alan Kazdin and Stacey Blase) published an article called Rebooting Psychotherapy Research and Practice to Reduce the Burden of Mental Illness. The classical idea of the practitioner-client dyad talking may be efficacious, although there is much room for improvement. However, it definitely constitutes a statistical impossibility to reach the millions in need. How many therapists would be necessary to treat all those who seek help? How many persons do not know that their suffering can be therapeutically addressed? In order to help overcoming this and many other problems, it is increasingly necessary to incorporate digital technologies into clinical psychology. Digital technologies can provide clinical researchers and therapists with key elements and its consistent integration into clinical psychology may imply a real progress within the field. In this regard, not only pragmatic problems (e.g. how to reach more people in need) could be solved, but also structural aspects that are defining in the constitution of the discipline (e.g. epistemological aspects such as how to integrate science that look for patterns across persons and subjectivity that is absolutely individual, even ineffable).
So, how technology can specifically enhance technological treatments? Some examples…
1 – Better personalization/customization
Clinical decision-making should ideally be made, depending on patient’s individual profiles. Historically this has constituted a source of great controversy: Goal standard of psychological treatments are Randomized Control Trials (RCT; conducted in experimental settings, in which the manipulation of the variables is more feasible than in “real world” settings). Nevertheless, many controversies regarding RCT’s have casted doubts on its undisputable utility. Principally, it is argued that the obtained results are strong evidence for certain groups of persons who supposedly share some clinical characteristics but actually are very divergent in crucial features for the treatment response being very difficult to translate them into real contexts. That is, two persons diagnosed with the same disorder may share some symptomatic characteristics, but may markedly diverge in the etiology, the phenomenology and the concrete maladaptive behaviors. This derived in clinical guidelines for clinical disorders that many times clinicians do not find that are proper for the client that have in front of them. Traditionally, this has been solved by the therapist’s intuition and clinical experience to adapt those general rules obtained in the laboratory to the everyday practice cases. However, new technological developments and statistical improvements may help bridging this constitutive gap. Currently, there are 2.32 billion people in the world using smartphones, key for the monitoring of electronic records. In this way, for example biosensors or ecological momentary assessment (EMA) developments (also known experiential sampling methods, e-diary or ambulant assessment), may allow to collect a great amount of data which in turn can be analyzed through novel statistical methods. This procedure may help to provide clients with more tailored interventions and tend to the personalization of mental health treatments.
Key technological development: machine learning techniques, wearable / portable devices, ecological momentary assessment and interventions
2 – Greater dissemination
Internet interventions have showed to be efficacious for the treatment of a wide range of mental disorders. The utilization of these treatments, even if not technologically complex (e.g. without artificial intelligence processing incorporated so as to create a reciprocity between interventions and people’s responses), are crucial given the fact that nowadays internet connection has spread out in massive ways, reaching even inhospitable places. This kind of treatments, in addition, can be self-applied or blended with traditional treatments allowing in the latter case to reduce the number of face-to-face sessions and thus dropping the costs. Although it may be true that there are many unknown aspects to be investigated before to conclusively establish how these treatments should be implemented (e.g. how much human support is needed) and for whom should be indicated, current results are very promissory for many persons. The same applies for ecological momentary interventions that are still much less developed but are potentially vital due to the massive utilization of smartphones in all regions of the world.
Key technology/development: Internet interventions, ecological momentary assessment and interventions
3 – Resolution of the “Controllability vs. Applicability” tension
Therapist consultant settings may provide the ideal atmosphere to build a good therapeutic alliance, which has proved to be a robust factor of outcome in face-to-face approaches. Besides, it is a proper space so as the client feel secure and out of danger. Nevertheless, the key aspect of therapeutic gains is associated with the possibility to translate what is being shared, thought, learnt, talked and experienced into real life. This transference is sometimes very difficult to be achieved. Mixed realities can facilitate the equilibrium, providing the controllability of the therapeutic setting but enabling to be applied and practiced in significant environments for the person. Whereas in virtual reality there is no contact with reality, augmented reality constitutes an interplay between virtuality and reality in which virtual elements are incorporated into reality. Different examples have shown the efficacy of VR and AR based treatments for a wide range of mental disorders and with the decrease of costs in this kind of devices a great expansion in research and practice may be expected for the upcoming years.
Key technology/development: mixed realities
4 – Reduction of stigma and shame
A person can easily share that has to undergo a heart surgery or that cannot go to work due to a flu, an infection or many other physical diseases. However, the same person would probably hide the truth if the reason of suffering would be a very anxious state, an inability to interact with others, an addiction or experiencing the blues. And this reaction is the direct consequence of a common belief that stipulate that we are more responsible for our psychological than from our physical health. Moreover, mental illnesses are associated to our identity whereas physical problems, even chronic illnesses, some of which may be more subject to be stigmatized, are more related to external entities that precisely came from the outside. In this sense, there are a vast array of applications (only few scientifically validated) and internet interventions provided by public and private institutions that can be started without the need of attending a physical place and thus prevent people from avoiding a psychological treatment due to the fear of being stigmatized. Although this is important and may help many people who otherwise would not start a psychological treatment, it is very important to address the root of the problem by an active commitment of health professionals as well as lay people to raise public awareness against the stigmatization of mental disorders.
Key technology/development: anonymous login to the interventions / access to treatments without attending a physical place
5 – Increase of engagement and motivation
There are few things more consensual in the field of clinical psychology than the trans-theoretical principle of motivation to change. Briefly put, the more motivated and implicated a person is to change, the more chances there are that a person undergoing a treatment will have a positive outcome. From the technological point of view, serious games (SG), defined as the utilization of game-playing features for different purposes than the ludic one, constitute a powerful tool to augment the intrinsic motivation of clients and users, and thus increase the engagement of them to the interventions. Although this may be particularly true for children and adolescents, it is not exclusive for them since adults have also proved to increase their engagement when gamified situations are incorporated.
This point should be nuanced as long as this engaging strategy could work only if the person is prepared to change, understanding the problems that she or he may be experiencing, having the commitment to solve them through a psychological treatment.
Key technology/development: serious games
Integration of the diverse technologies
It is important to mention that the real progress would be achieved if an integration of the diverse technologies could be achieved. As an example, an internet intervention that may help a person living in the countryside without any psychological centre nearby, could be enhanced by the incorporation of EMA for the ongoing assessment as well as gamification features so as to increase the engagement or the incorporation of a virtual reality application to train different features in customized created situations.
Finally, it must be outlined that new digital technologies are not free of caveats and challenges, which despite being out of the scope of this article, are also treated and considered by the scientific community. In this sense, it is essential to grasp that the word technology derives from the word technique, which in turn derives from the word tool. In other words, technologies are instruments that can be used in the same way than a hammer: to repair a wall or to damage it. If the former prevails over the latter in the mental health realm, most probably the quality of life of worldwide population will improve. That is our aim.
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Javier Fernández-Álvarez is a PhD Student and Early Stage Researcher (ESR) based at Università Cattolica del Sacro Cuore, member of the AffecTech – Marie Skłodowska-Curie Innovative Training Network (ITN). The AffecTech project conducts international research into wearables technologies for mental health, and has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 722022.