Keynote by Prof. Dr. Bruce Wampold ‘Mental Health Services: At a (Technological) Crossroads’

but it's an honor to introduce to you Professor Bruce uh wompult Bruce wampold was trained as a mathematics at the University of Washington before earning his PhD in counseling psychology at the University of California in Santa Barbara his work involves understanding psychotherapy from empirical historical and anthropological perspectives which has led to the development of a contextual model of psychotherapy his work is summarized in the book The Great Psychotherapy debate the evidence of what makes Psychotherapy work he is a fellow of the American Psychological Association and the Diplomat in counseling psychology at the American Board of Professional Psychology in 2007 he received distinguished professional contributions to applied research award from the American Psychological Association he is also an honor honorary doctor in the social sciences at Stockholm Young University the floor is yours well I'm very pleased to be here in this wonderful City with beautiful weather I know it's like this all the time right sunny and crisp warm so thank you for the invitation to talk about Psychotherapy I'm retired from my professor position so any chance to give a lecture is always appreciated so the challenge today was to talk about the future of psychotherapy and mental health treatment and of course uh it's always difficult to predict the future but it's a really important topic because we're at a Crossroads so let's just review a little bit about the history and not just simply the history of psychotherapy but history of humans so seven million years ago our ancestors started to walk upright so that's a long time ago of course one million years ago we developed language and communication and clearly the human was evolved to use these languages many species had Proto languages and humans perfected this in various ways you know evidence that this is an evolutionary process is the different civilizations developed different languages so very different tonal languages from phonetic languages and so forth 125 000 years ago a tremendous event in human history was using controlled fire for primarily for cooking but it also brought people together in community so it was a social event as well as a technological event twelve thousand years ago and which was uh according to many anthropologists and historians uh seminal event was agriculture so uh uh a evolutioned away from uh hunting and Gathering to raising crops nearby communities five thousand years ago written language now the evolution of language to communicate was pretty natural for humans written language was purely a human invention it was difficult to do there was no agreement about how you spell words or how you might punctuate and use grammar and it took centuries for this to become standardized two thousand years ago are a little more Christianity so the evolution from multiple gods to one God over five thousand years ago but Christianity predominant uh one of three predominant uh religions uh two thousand years ago and then we have only 120 years ago Psychotherapy this is a recent invention and it's not entirely clear whether it was a Natural Evolution or just something that Freud and others thought would be a a good way to treat mental illness so let's talk about Psychotherapy events I won't go into detail but you can see I kind of put the origins of psychotherapy in Descartes dualism because until the mind-body dualism mental illness and physical illness were not distinct his same practitioners same processes um different depending on how the civilizations discussed it but clearly with the beginning of Descartes we could think of uh psychological distress as something distinct from physical distress and then you look at kind of the seminal events in Psychotherapy and it was only in the 1950s that in the United States and many other countries was a requirement to show that various medical procedures were actually effective so the randomized clinical design as a way to test Effectiveness is a recent occurrence so I bring this up because we want to put Psychotherapy in the context as this recent invention we have an idea about how it works but we really don't know so I like to think about how Psychotherapy could work we sit in a room um the moral process is 50 minutes a week and talk about the patient's life maybe assign some homework and different activities but primarily it's this 50 minutes how can talking to a person in a room result in effects it's quite amazing when you think about it so what do we know about Psychotherapy and I think we all know this and hopefully we all believe that Psychotherapy is effective and you know the research is pretty convincing it's demonstrated in randomized clinical trials comparing Psychotherapy to weightless controls for instance so no treatment Psychotherapy for nose treatment the effects are relatively large um it's also been demonstrated in practice so practicing psychotherapists get effects that are comparable to randomized clinical trials and this frankly is is quite amazing really because in clinical trials the patients are screened severe comorbidity is ruled out the therapist gets special training they're selected for their expertise and so forth and they get this wonderful supervision many clinical trials you get one hour of supervision for every hour of therapy delivered quite a luxury yet in practice the effects are comparable Psychotherapy is as effective as medications for most mental disorders so for anxiety and depression particularly but others as well Psychotherapy is longer lasting when you withdraw medication the relapse rate is relatively large whereas if patients for the same disorder receive Psychotherapy the effects are longer lasting of course Psychotherapy has fewer side effects than let's say antidepressant medication um and Psychotherapy is less resistant to additional courses so the second or third or fourth time uh somebody receives Psychotherapy is just as effective as the first Administration not true in medication so um as you heard I was trained in mathematics so I like numbers so the nnt of psychotherapy is three what does this mean well nnt is the number needed to treat it's the kind of statistic that's the cheerleader for medicine so how many patients have to receive a particular medication or procedure in order to get one additional success okay so the nnt of psychotherapy is three that means every three piece patients treated we have one who experiences a benefit that's greater than they would have received had they not received psychotherapy well in a sense that sounds kind of depressing right so two out of the three patients we see would have comparable outcome staying home well again Psychotherapy is as effective as medication for mental disorders and if you look up the nnts for most Medical Practice you'll see that they're quite large actually so look at Cardiology open heart surgery removing blockages coronary blockages nnts of 15 or 20. as well as nnts that are very high for side effects okay so Psychotherapy does all right but clearly there's a room for improvement so what makes Psychotherapy work well I'm talking about the future of psychotherapy so tomorrow I'll talk a little more about uh what are the actual mechanisms to make Psychotherapy work but what do we know about mental disorders in their treatment and here I'm going to talk about statistics primarily from the United States and different epidemiological studies but they're not too different in Western Europe so it looks like uh between only between 30 and 40 percent of those with uh a psychiatric diagnosis actually received treatment okay and this is in the last 12 months so if you have a incidence of mental illness only 30 to 40 percent will receive any mental health treatment that seems to be increasing not rapidly but but a bit okay who treats patience and again this is uh uh from the United States but it's interesting so psychiatrists in the United States primarily are biologically based so uh it's very very rare anyone receives Psychotherapy from a psychiatrist in the United States but about 12 percent of those patients who are treated receive treatment from a psychiatrist so non-psychiatrist Mental Health Specialists about 16 percent of those treated receive this treatment primarily Psychotherapy so this is where we see uh people suffering receiving psychotherapy but now if you think about it that's 16 percent of the 40 percent who are getting treatment so six percent of those suffering from mental illness or distressed psychiatric diagnosis actually receive psychotherapy so of course as psychotherapists and students of psychotherapy we think about this as the most important and the most helpful treatment but only about six percent of those suffering actually get or take advantage of psychotherapy in many communities in the United States people don't want to go to psychotherapy it's a cultural practice accepted by primarily educated people uh knowledgeable of different treatments so there are many communities in which Psychotherapy is really not an accepted practice and of course around the world in many uh countries Psychotherapy isn't even a practice that would be considered it's it's not available it's not familiar again this points to the fact that Psychotherapy is a cultural practice so in the United States the um most mental let's put it this way the the treatment that most patients receive for mental uh or psychiatric disorders is from a primary care physician so the physician you see for common colds for the flu for minor traumas and so forth is also the practitioner that treats mental disorders primarily with medication in the United States other Human Service Providers Social Work nurse practitioners provide Mental Health Service and then complementary and alternative providers as well and I'll talk a bit about more about that so let's look at some Trends in American Psychotherapy um the payment for providing Services really has been stagnant for probably two decades so particularly if the psychotherapist is paid through insurance through some government program or through business and industry directly the reimbursement rates have been pretty stagnant and now are quite low uh around the world as well as in the United States mandating shorter treatments so often in the United States if you're patient's been diagnosed with major depressive disorders through uh payer might say you're limited to six sessions okay uh another trend is that psychologists psychotherapists which I am um are relatively expensive you know we spend more years getting training where you have a Professional Organization the American Psychological Association that lobbies to benefit our payment and so forth well it's cheaper to hire licensed professional counselors which is a like a master's degree therapist as opposed to a a doctoral level psychologist in the United States as well as mental health technicians now this is a consequence of manualized evidence-based treatments because if there's a manual you can follow for six session treatment for major depressive disorder and it's following the manual then you don't need a well-trained six years of training to be a licensed psychologist in the United States when you can teach a technician to use uh a manual increasingly around the world the type of treatment is mandated so in many countries not only there's a number of sessions Limited but the treatment delivered is mandated so in the National Health Service in England for instance cognitive behavioral therapy is the treatment that's offered to everybody it appears in the guidelines the nice guidelines and all of the therapists need to be trained and deliver cognitive behavioral treatment another Trend around the world is a shortage of therapists okay in the United States it's very difficult to find a therapist who has room in their practice to see you so you can um often the United States you belong to a particular insurance company they have a panel of therapists they recommend one of their therapists only um the wait list is 6 to 12 months nobody has room in their practice so there's this shortage of therapists all of this could be seen as a consequence of incorporating Psychotherapy in the medical practice of various countries and we could go through that in some detail but it's this idea that Psychotherapy is a medical practice has been tremendously important for our development because we get paid through these medical systems but it's also really changed the way we do psychotherapy okay back to this idea about as we're we're psychotherapists or psychotherapists in training um and we believe that sing a psychotherapist is an important event in people's lives and many people say whether you're suffering from a diagnosis a psychiatric disorder or not this is a way to improve your quality of life but it's not the only way people change okay uh John Norcross has done several studies and summarized the data people change by reading a book so how to make your life better actually produces large effects internet CBT so there are many programs developed several recognizable ones from Sweden at Lynch ping University and the research seems to show that internet CBT particularly for anxiety disorders but also for other disorders is as effective as face-to-face supervision so there's some problems with the research because the people in these trials are ones who think that internet CBT is a is a viable treatment there's also internet psychodynamic therapy which turns out to be as effective as Internet CBT self-help groups okay alternative methods acupuncture meditation a number of different methods and we have to think that for some people these methods are just as effective what about psychics religious uh figures traditional healing practices in many countries and Indigenous communities bartenders friends intrinsic methods thinking about how you can change on your own I put psychics in red because Scott Miller and colleagues did a survey and it turns out many people visit psychics you know talk to your dead relatives in another world and it turns out that in the United States people pay for psychics as much as they do for psychotherapy okay so of course we don't get government reimbursement for going to see a psychic but what's interesting is that the pay the we won't call them patience but the individuals who see psychics actually experience change on the order of magnitude that they experience with psychotherapy so again this idea that Psychotherapy is some special treatment that is needed for the treatment of mental disorders um probably not true or I should say maybe demonstrably not true placebos there's lots of work that taking a placebo for a mental disorder will result in significant change in fact or of incursion in several really brilliant meta-analyzes have shown that 90 95 percent or maybe even a hundred percent except for severely depressed people antidepressants are a placebo effect so the psychiatrist and the primary care physicians prescribing antidepressants who really are extensively prescribing placebos we did a study in which we looked at the differences in effects among psychiatrists giving antidepressants and it was a double-blind study so half the patients received placebos half antidepressants of what we found out is the most effective psychiatrists got larger effects giving placebos than the poor psychiatrists got giving active medication so much of the effects of treatments for mental disorder are placebos I know that's kind of well we just give placebos but placebos are are quite amazing and I'll talks in detail tomorrow about why that is so just to change the subject quite dramatically I want to talk a little bit about the history of computing and I'll make the point why this is relevant so 1821 like many people credit to the beginning of computing machines as those babbages steam driven calculating machine it was quite an elaborate machine in it creative and and quite Innovative Ada Love Like Love lace Lord Byron the poet's daughter wrote the first computer program 1931 differential analyzer Alan Turing mainly a theorist rather than actually development of a computer I had this challenge that the Computing machine could be differentiated from a human so the Turing test is if you interact with a computer uh could you be indifferent about whether it's a computer or a human and that's an interesting idea and there's still apply the Turing test to various Endeavors Hewlett-Packard company first kind of Mainframe computer in 1945. univac was probably the the first bona fide Mainframe computer first computer language the computer chip so until that time they were all trans first tubes and then transistors but then a computer chip internet of course uh 1973 to many of you this is a long time ago to some of us is it's just just uh halfway through our lives Apple computers Bill Gates Microsoft and personal computers Google of course it's a it's a verb now you Google something Facebook in 2004 pretty much uh computer was as skilled as a chess master in doing chess and actually the recent competition being Magnus Carlson and Neiman from the United States Carlson accused him of cheating by getting information from a computer about what would would be the best move so here's computers doing a human endeavor as effectively or more effectively than a human the reason why this is important is that computers developed at the time same time frame as psychotherapy okay Psychotherapy a particularly human endeavor right sitting in a room face to face with a human and on this altar alternative track we had the development of the computer 2022 we do most everything on computers right we often have chats with some computer site we want to buy a product and you don't actually know am I interacting with a human or am I interacting with a bot and it's very difficult to tell I try to ask particular questions but they're pretty good so let's talk about what happens at each of these transitions language written language I probably should have put in that timeline the printing press because that was a seminal event in human history but at each transition there's this fear we're going down the wrong road this is the end of human civilization as we know it so here's Carl Britton breidenbau president of the American historical Association again in 1962 in his address presidential address to the American historical Association he said human existence were going through this god-awful great mutation okay we are now suffering something like human Amnesia any lamented about the decline in reading people are no longer reading like they used to and we're also quite distanced from nature and he said these ugly Kodak Kodak boxes right cameras and transistor radios so I call this the Carl effect because at each stage of development we say we're going to damnation because of some technological advance well in terms of psychotherapy we'll see many times I feel like saying yes Carl you're right because things are changing well biggest change or most apparent Change Is We Now do much Psychotherapy not in a room face to face but we do it over some kind of a video platform Zoom or or some other video platform and this was a necessity because of covet well like working at home we're probably not going back to giving exclusively face-to-face Psychotherapy okay the United States many companies want their employees to come back and they go we're not coming back we don't even live where where our business is anymore we've moved we don't want to drive the distance is too great well same in Psychotherapy we're not going back many patients prefer video there's no disruption of life you don't have to find transportation to a therapist office there's a stigma I don't have to walk into a waiting room with crazy people I'm not like them right I don't want to be seen in a mental health clinician's office it's convenient and many patients report they're more self-disclosing there's something a little less personal in a video conference again it's it's not what's true it's what we perceive to be true so we're not going back maybe somewhat but not entirely well the corals out there would say you can't do effective Psychotherapy on a video platform it's difficult to form an alliance you don't see the non-verbal behavior in the same way it's not that human close proximal distance that's important for a human connection okay but you know it's a modern world many people do much of their social relationships online so again we think oh these young people they're they're on Facebook they're on social media Tick Tock this is the way they communicate with each other um social relationships are changing the way so here's a surprise video Psychotherapy is as effective as face-to-face Psychotherapy so the those of us who are Carls um we're going to say it's not as good you can't do it this way it's the end of how we do psychotherapy but it works okay several meta-analyzes we've done a large-scale study of patients before covid after covid matched on a number of variables and the benefits of video delivered psychotherapy are about equal to face to face so what happens well in the United States we have these huge companies talk space and better help so you don't have to go to well you don't go to a phone book anymore to look for a therapist in your community but you go to Google right and you look up therapists now you just join talk space or better help and you can find a therapist anywhere in the United States to help you okay so you don't have to uh look for somebody in your community who's available and it may be that you live in a small community there are no therapists or all the therapists are extremely busy I just get online and find a therapist somewhere by the way these are billion dollar companies okay this is not as we say small potatoes okay and the problem these companies are having finding therapists so as a licensed clinician I get an email probably once a month asking hey why don't you come work for us and they don't say it's working for a talk space or Better Health usually this one's better help but they usually just say we're looking for therapists this is a great way to have a practice there are some advantages for therapists because they don't have to leave home um they can see patients anywhere so they don't have to worry about finding patients so and oh a third Advantage is you can work anytime you want so you can put open slots in your calendar and potential patients or continuing patients pick what slots you have open so if you want to work three hours a week you can do that have three particular slots interesting Better Health spent over a hundred million dollars last year in advertising so the reason I want to emphasize this is this is big business so we're no longer Psychotherapy individual practitioners kind of in business for ourselves or in a small group practice often in the United States with maybe five to ten psychotherapists in the same practice now we're part of a billion dollar company making money from us by the way therapists hate better help and talk space there's a reason why they can't find therapists the remuneration is is low so they'll take each take about half of your income or half of your fee so you receive about half okay it's convenient there's no insurance form there's no paperwork you just get online see your patient and be reimbursed well what about mental health apps I can't find a therapist the stigma is too great I don't want to see that's only for crazy people I don't want to see we say the vernacular I don't want to get my head shrunk right and go to a shrink it's it's for uh crazy people and and others like that so how do you get help well again John Norcross studied bibliotherapy most people don't get books anymore they get a mental health app so in 2017 there were more than ten thousand mental health apps for your phone and you can go to your your Google Play or your Apple Store and put in mental health and you'll get a listing of these apps okay in 2022 in the United States over 500 million dollars was spent on the apps yeah and I should give you I didn't put the slide for this but the uh they call it the click rate how many people once they buy an app and download it on their phone actually use it and it's pretty low okay it ranges um uh still using it a week later is about 20 percent okay but if the 20 percent respond and do well that's an improvement in mental health so there's an app for everything of course on your phone diet physical activity mind training sleep so why not Mental Health well part of the problem is there's no oversight to these mental health apps we don't know if they're effective their for-profit businesses using the high prevalence of mental disorders to make money uh the data collected on Mental Health apps the United States are not uh regulated by our health security law HIPAA okay so uh you know if you see a mental health professional or a physician that information is strictly restricted in various ways it's not true for mental health apps so the information collected could be shared so here's an article from The New York Times how to find a mental health app that works for you okay and they go through how to do this it's not that easy you don't really have any good data about effectiveness of course you have ratings this is a four star it was great the service was good the dinner was delicious I really liked the ambient oh that's restaurants the ratings are similar to restaurants okay let's talk about electronic solutions for mental health problems well how can we use electronic applications in face-to-face uh Psychotherapy well we can do electronic scheduling record-keeping billing email and many apps for chatting with your patients so this is the traditional Psychotherapy model in a sense augmented by electronic Solutions not very interesting they're relatively helpful of course the United States particularly for billing and scheduling is and record keeping girlfriend but I would say probably not much Coral reaction to this okay it's still face-to-face supervision I don't think any of us really have too much difficulty thinking about using an electronic platform for scheduling then we have the electronically delivered face-to-face Psychotherapy this is the better help and talk space it's as effective but it's it's problematic in the idea that these large for-profit companies are kind of managing How We Do psychotherapy then we have computer assisted therapy and and you know internet CBT has been around for 15 I should think about this 15 or 20 years probably so this is not something uh too remarkable computer assisted therapy it's effective randomized clinical trials pretty established that getting some kind of treatment usually CBT because it's easier to implement in a cognitive in a internet based format but what about the alliance we know Alliance is important in Psychotherapy where's the alliance in the internet CBT so we'll talk a little bit about that today and then there's apps with no therapist in the background well I should mention in the internet CBT most applications there is a therapist in the background so the therapist might look at the data and progress write notes to the patient the patient can write notes to the therapist different degrees of therapist in the background involvement and again this is evolving so the therapists in the background is increasingly a bot not an actual therapist and then there's the apps with no therapist in the background so you have difficulty with depression well let's do anxiety and your mental health app will educate you so you get psycho-education about anxiety you might get some exercises to do some exposures to do but all without any interaction with a professional then we have and this is my biggest Carl for me personally is precision mental health and the idea of precision mental health comes from precision medicine in a Precision medicine um no you have some type of cancer well there's a standard chemotherapy for this particular kind of cancer Precision mental health measures your genome it knows uh your physiology to a precise degree and you get a therapeutic tailored to your particular body so it's a Precision treatment based on your particular genetic makeup and physiology so in mental health we have this attempts to do Precision medicine so we could match the patient to the therapist we know that some patients seem to hit it off better with some therapists there's not much data to support that but it's a conception so the ideas we're going to match patients to the therapist based on their diagnosis so some therapists according to this model may be better treating borderline personality disorder for instance so if you have a diagnosis of borderline personality disorder then you get matched with a therapist who's more effective with that particular diagnosis but also match then on personality what kind of uh personality what kind of History do you have and there's attempts to do this in a way well part of the problem is there just aren't enough therapists so it's really hard to match I just want a therapist who can see me within a month if if I have to wait for one whose matched precisely for me it might be a longer waiting list but we also want to make attempts in Precision mental health to match the patient to the treatment and not just the type of psychotherapy okay okay we could do an assessment and say you're going to respond more quickly to CBT than you would to psychodynamic therapy for instance that would be to the type of psychotherapy but many of the medical organizations in the United States are matching you to the type of service you need so some kind of Step care where we might say well patients like you respond quite well to a mental health app so we recommend this particular app and you can't see a clinician because we've determined that this particular treatment is most effective at your stage your history your personality and so forth I show the picture of the supermarket because when I go to the supermarket I want to be able to pick my own vegetables right I don't want to say what's most healthy for me is salary and spinach because I want cauliflower and carrots okay well Precision Mental Health uh uh doesn't take into account patient preference okay I've had this discussion with several of the organizations that do Precision mental health in the United States and I say what about patient choice this is a patient who doesn't want an app wants to talk to a person doesn't want medication well no we know what's best for them so there is there is a um uh a danger to this in my estimation but it could be you know I'm Carl Britton bow uh that's the end of the world Precision mental health uh so just uh article by Len bickman who's been kind of on the Forefront for many decades in measurement-based care and using various assessments to guide mental health treatment and he talks about the 50-year journey from randomized experiments to artificial intelligence and precision Mental Health foreign applications we really need to talk about not what's happening but what needs what are they actually address so here's my list of what we can address with various electronic and software Solutions of course the first thing we want to address with any kind of intervention is does it actually work to reduce distress okay we also want to address with electronic applications of access so the biggest problem in mental health in the United States is actually access to care either a psychotherapist or a psychiatric psychiatrist so this is why most psychiatric medications are delivered by primary care physicians because you can't get access to a specialist mental health provider well how can we use electronic solutions for therapist education so I look in the audience I know some of you or students think about your training is there some uh application electronic application that aids in your training well you might get video tapes of your sessions to use in supervision that's hardly a modern software solution um I put in that therapist education training and Improvement measurement-based care so I didn't talk about it much today but we know measuring the progress of our patients and providing that information to the therapist makes a difference and most of that's done electronically now and again then even if you're in traditional Psychotherapy practice software Solutions can provide assistance to the therapist so the question is uh are we progressing so are these software solutions that are available actually resulting in better Mental Health give you a couple of examples here this is uh Benedict Kerry he was the mental health journalist for the New York Times for I think three decades or more okay I had several in her interactions with Ben about different articles he was writing and he said you know when I started as a journalist in mental health I had this hope that throughout my career I would see breakthroughs so that there were more dramatically more effective mental health treatments and what he basically says in his farewell address there isn't the prevalence of mental disorders if anything is increasing and treatment Effectiveness is stagnant so we're not really progressing in that way even more distressing is Thomas Insel who psychiatrist who was the director of the National Institute of Mental Health in the United States directed The Agency to focus on biomarkers neuroscience genetics and medication treatments for mental disorders billions of dollars were spent on these Endeavors under his leadership okay the funding for Psychotherapy and and kind of uh humanistic kind of treatments in the sense that we're meeting face to face with our patients uh disappeared we couldn't get funding for research well at the end of his uh tenure at the NIMH he wrote a book lamenting the fact that we wasted billions of dollars because we didn't progress there's no major breakthrough we don't have biomarkers for mental illness that lead to early intervention to prevent let's say severe mental illness like psychosis doesn't exist so at the broadest level are electronic applications helping kind of this technology I would say no nearly all electronic applications and electronic Solutions are untested the effectiveness is unknown okay but I want to look at some promising examples and here I have a conflict of interest because these are different Endeavors which I'm involved with and the reason I use these is I have criteria for which companies I will do um some work with first the company has to be based on Quran evidence is this a legitimate Endeavor which you could say the architecture is based on what we know about mental health and its treatment does it partic address one of those particular issues we talked about Improvement access and so forth training is another one and are the companies willing to collect data on their effectiveness and examine evidence if they meet those criteria then I'm willing to be involved so here's some examples this is uh listen and it's a company actually founded in part by my former student Zach emmel that uses natural language processing to analyze Psychotherapy sessions so it records a session creates a transcript analyzes us with the latest artificial intelligence and machine learning by PhD computer scientists in natural language processing and then gives the therapist feedback about empathy about the degree that they're following treatment protocol for instance has been applied for motivational interviewing are you adhering to the principles of of a motivational interview what's interesting is many um computer scientists interested in this natural language processing are very eager to work in the Psychotherapy space because they think this is an application that actually has a benefit for society you know they're paid astronomical wages to work for businesses for-profit businesses on different processing of natural language but they want to work in the mental health space so it's exciting what you can do with this area peer Collective is um providing online like Psychotherapy interaction with a peer counselor so somebody not with a professional degree so you'd say well how is this scientifically based well first of all we have evidence that peer counseling getting support and empathy and even some advice from a peer counselor is very effective and actually preferred by many mental health patients for a variety of reasons but how this is scientifically based is I've worked with them to screen peer counselors to be able to give them a challenge test and pick those that are most effective and then use some deliberate practice technology to train the peer counselors so it is an electronic application not only in the selection of the or or the provision of the peer counseling but also in um the delivery and the training of the the peer counselors uh formulator is a finished company working on uh um electronic software solutions for case conceptualization and the idea is that the patient interacts with this system and gets a formulation about their difficulties which is useful for the patient but also for the therapist to get an idea of the patient prior to treatment meal mind is a company that produces psychotherapy sessions that patients can listen to so instead of actually going to a therapist you can listen to a therapist giving therapy to somebody with a problem like yours a person like you and patients are people in distress we shouldn't call them patients because many of these people don't want to see a mental health professional but find this particularly useful and the the sessions have homework so they're things for the the individual listening to do so it's kind of vicarious therapy if you think about Albert bandura I'll skip this one this is my one I'm most involved in this is an electronic platform for learning therapy skills so you get a video of a particularly difficult interaction and you respond as if you're the therapist and then you can watch your response practice it again over and over submit it to an instructor or supervisor for feedback it follows the principles of deliberate practice okay we know experts in musical performance in athletic what makes an expert performer this idea of deliberate practice so I want to talk just for two or three minutes about the alliance because the coral of us are going to go well you need an interpersonal relationship we know in fact Bruce you're the one who's produced a lot of research showing the relationship is absolutely critical uh to success of psychotherapy and now you're standing before us talking about these software Solutions so you know we have a lot of relationship factors we call them different things Alliance collaboration goal consensus empathy congruence genuineness the real relationships and so forth Ah that's a lot of relationship factors but it turns out you can break them down to two primary components the warmth of the therapist and the competence of the therapist and actually this applies to medicine as well you know it's interesting in the basic social science Susan Fisk a famous psychologist said they're two Universal dimensions in social cognition warmth and competence okay I'll give you just a quick example of these two when you're lost in a City foreign city and you don't know how to find your hotel it's dark at night your phone ran ran out of battery so you can't use Google Maps you have to ask somebody well you have to determine is this somebody who's going to help me or somebody who's going to rob me of my possessions right so this is kind of the warmth Dimension is trust caring support and you have to make the determination and every Psychotherapy patient makes this determination this is somebody that cares for me who has my best interest in mine okay so that's the warmth you found somebody they're really helpful to help you find your hotel next you have to determine are they competent and my wife and I have traveled all over the world and we we have our favorite countries where people are so helpful yeah it's right over there and we know absolutely they have no idea where they're sending you but they have to be helpful so you have to determine are they competent to help you so that's the second determination a Psychotherapy patient makes okay is this a caring warm genuine empathic uh provider and do they know what they're doing is there a treatment that makes sense so Alia Crum has done some research on on this talks about it as when your doctor gets it that's the disease that's the competence and gets you which is understanding you as an individual and we've done some research where we've Factor analyzed all the relationship factors and we get these same two factors patients make a determination about warmth and caring of the therapist and of whether the treatment they're being given is going to be effective and if you think about it on the warmth and caring side are the humanistic therapies motivational interviewing just talking to a warm caring person this is uh Bill Miller who developed motivational interviewings book on listening well it's not a Therapy book it's a human relations book and of course cognitive therapy more on the competence so when people get internet cognitive behavioral therapy they're really looking at the determination is this a useful treatment so it might be that they aren't really needing a warm caring provider they need someone treatment so they have a good attachment style good social support the program may be enough and it turns out that in the internet treatments there's an alliance with the therapist in the background and there's an alliance with the program and they measure these separately and it's alliance with the program that it's a better predictor of outcome than an alliance with the therapist although in this meta-analysis that Christoph flukater and colleagues conducted on the alliance all the studies that had been conducted found that that the alliance with internet provided treatments was a predictor of outcome so the alliance is not simply with a warm caring relationship in a face-to-face situation but it's also with the program and the uh a provider that's in the background so I'll skip this because it looks like I'm running out of town time so conclusions well there's no going back okay electronic Solutions are here we can't be uh our inner Carls and say this is the end of psychotherapy I don't want to be involved it's our responsibility as mental health experts to guide the development of the electronic applications so the basic question is are the various products software Solutions actually Solutions are they helping and we need to be involved in their development and in the research on their development so thank you [Applause] we have time for a few questions I guess we have time for two questions okay good so thank you so much for your talk um it's always very uh strange and but at some point understandable to see how so many of these apps are untested but I was wondering isn't this the same for face-to-face Psychotherapy in real practice because for many of us when we provide therapy I will just speak for myself I think that's easier we don't really have a good idea about what is our personal outcomes are they as good as what is happening in trials and so my question to you is is there something we can learn from the development of these apps perhaps some of those that you're involved in that we can apply to some of these more personalized or personal treatment settings yeah it was a wonderful point isn't it we've tested psychotherapy at a ideal level so the clinical trials um uh determine whether a particular treatment cognitive behavioral treatment or psychodynamic treatment is more effective than Alternatives or no treatment but does that apply to a particular patient in a particular situation and I think here we have to really think we should be using some kind of measurement-based care where we're measuring our outcomes because the point is well taken without that we really are providing an untested solution to a patient I agree what can we learn as a therapist from the applications for me the the the the research that is most kind of impactful for me is this idea of alliance with a program so it it's not just the belief in me as a therapist oh my therapist is so warm cares for me but has to be I provide my patient a rational and believable and cogent treatment plan with discreet actions for achieving those goals so for me that's the biggest takeaway from this and I think as we see applications increasing usage that they're going to become more focused on actual steps for achieving and we can do that I think to a greater degree or at least keep it in mind to a greater degree in it in her own treatment thank you thank you

2022-11-07 16:50

Other news