How can we introduce new technologies in CBT to children and adolescents? - Chapter 23

What is this chapter about?

Laptops, smartphones, tablets and other technological means can no longer be imagined out of an adolescent's life, and the new generations grow up with them from an early age. It is therefore a logical approach to involve such technologies in the transmission of CBT.

What computer-based psychological treatment programs for young people exist?

CBT is effective for treating children and adolescents with many different disorders. So why is technology needed in treatment? Unfortunately, most young people with mental health problems do not get the professional help they need, partly because of their shame, stigmas, confidentiality concerns and beliefs about CBT treatments. In addition, structural factors (such as finances, difficult accessibility and long waiting lists) are also hampering. The use of technology can remove almost all barriers. Despite the many benefits of computer-based therapies, these are not a perfect solution: children who do not have access to a computer, for example, are also most at risk of developing mental health problems. That said, this group has an even smaller chance of receiving the right help in the traditional form, so computer-based therapy is always better than nothing. The involvement of the therapist can vary greatly from nothing (full computerized self-help program), or minimal (such as weekly email contact) to considerable (the therapist is there every session).

Fear

For example, there are multiple computerized treatment programs for children and adolescents with anxiety disorders, in which the degree of therapeutic involvement varies. Spence and colleagues have developed the BRAVE-ONLINE program (with moderate therapeutic interference): 10 sessions with the child, 6 sessions with the parents and 2 "booster" sessions after treatment. The effectiveness of this program in reducing anxiety symptoms has been demonstrated by multiple RCTs. Other programs are also available, for example a CD-ROM for adolescents with anxiety disorders (Cool Teens) in which there is regular telephone contact with the therapist, or a self-help website that does not involve therapeutic interference at all. Although the results are promising, more research is needed into its effectiveness.

Depression

The best-known Internet-based self-help program for adults and adolescents with depression is called MoodGym (2009). This program consists of five sessions and there is no therapeutic involvement. It has proven to be effective, but not as effective as traditional CBT in reducing depressive symptoms or negative automatic thoughts. A combination of MoodGym with face-to-face CBT works better than one of the two separately. An example of a self-help CD-ROM program for adolescents with depression is called Stressbusters. What is missing in the field of computer-based self-help programs for depression are the studies that examine the effectiveness of treatments in which the therapist mediates. Such mediocre involvement of the therapist could increase the effectiveness of self-help depression programs. So more research needs to be done on this.

Substance abuse

Schinke and colleagues have developed a number of self-help programs for substance abuse-related problems, most of which are on CD-ROM or offered over the Internet. These prevention and early intervention programs are not based on CBT, but on the family interaction theory that focuses on the relationship between adolescent girls and their mothers. These programs are completely independent (PSH) and even with this lack of monitoring by and/or support of the therapist, there are positive results.

Pain

Several Internet-based and CD-ROM based pain programs have also been developed. An example is the Internet-based CBT program Web-MAP of Palermo and colleagues (2009): it consists of 9 sessions in which the therapist has a supporting role, and focuses on managing pain in adolescents aged 11-17 years. This program is effective in reducing pain intensity and adolescents are less limited in their activities after treatment: an effect that persists 3 months later anyway. Time will tell whether full self-help programs are also being developed within this area that do not require therapeutic involvement.

Eating disorder symptoms and problems with body image

There are many CBT based self-help programs in which the degree of therapeutic engagement varies, as well as the way they are offered. An example of this is StudentBodies2BED by Jones and colleagues (2008) which consists of 16 sessions. Weekly e-mails were also sent with motivational messages. It has been shown to be effective in reducing BMI, binge eating and worrying about body weight and body shape. More research needs to be done on which method of transmission (Internet-based, CD-ROM, discussion forums) is the most effective.

What challenges are there?

All programs differ in their way of transmission and the degree of therapeutic involvement. In order to have a major impact on health care, such programs must be taken up by health departments. As soon as these programs become available to therapists in the public and/or private sector, there are a number of considerations that need to be made. For example, a consideration should be made about the way in which the self-help program is offered. Internet-based programs have the advantage that the client's data is easily accessible to the therapist. Because the therapist keeps an eye on everything, the client goes through the program as well as possible with the support of the therapist (occasionally an e-mail or telephone support). However, Internet-based programs have the disadvantage that they can be hindered by technological problems (including slow Internet). Do you, as a therapist, opt for an Internet based program (with all possible technological problems), or CD-ROM based version (where progress cannot be automatically monitored by the therapist)? Where Internet-based and CD-ROM-based therapies are very similar, discussion-based programs (discussion forums) are very different: now there may be online group therapy, where there is therefore the possibility of interaction with (and support of) peers. This way of group therapy is less confrontational and accessible than traditional group therapy. Two other considerations relate to confidentiality (there must be passwords, appropriate firewalls, and secure electronic storage of clients' data) and treatment loyalty as well as the pace of progress (both are less than with traditional therapies).

In summary, therapists themselves are modestly positive about the use of computerized therapies in young people, especially for preventive purposes and for psychological problems that are only mild to moderately severe. Therapists are less enthusiastic about the programs that do not require any therapeutic involvement.

How can technology complement CBT?

Of course, it's not the case that a full CBT treatment should be offered via computerized ways: there is also a lot of potential in using technology to complement the face-to-face CBT sessions. For example, chat rooms and discussion forums can be used to gain support and promote self-expression, computer games can be used to learn certain (social) skills and increase involvement in therapy, and mobile phones can be used to monitor mood, thoughts and/or behaviour.

Laptops, smartphones, tablets and other technological means can no longer be imagined out of an adolescent's life, and the new generations grow up with them from an early age. It is therefore a logical approach to involve such technologies in the transmission of CBT.